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KMAP BULLETIN: MCOs Retroactive Eligibility Procedures

Date: 04/15/25

KMAP GENERAL BULLETIN 25080 (PDF)

In an effort to simplify administrative processes and create consistency across Sunflower State Health Plan, UnitedHealthcare Community Plan, and Healthy Blue, all three organizations are pleased to outline a streamlined process for submissions of authorizations and claims payment in situations where a Medicaid member may become “retro-eligible” after admission or after services have been completed.

Here is an overview of the process. Refer to the individual managed care organizations (MCOs) for specific procedures.

  • Authorization for all retroactive eligibility services that normally require prior authorization may be requested after services are provided but should be requested prior to the claim being submitted. Each MCO asks that you indicate the authorization is for a member who would have been eligible during the retroactive period.
  • All three MCOs will continue to evaluate cases for medical necessity and apply benefit and coverage reviews, as appropriate.
  • Once the authorization has been approved and communicated, you can then submit the claim for processing. When the claim is submitted, it will not be denied for lack of prior authorization.
  • If the authorization is denied, you can reach out to the respective MCO for additional review. 
  • In situations where there was not an opportunity to obtain authorization prior to the claims submission and the claim was denied due to lack of authorization, all three MCOs have established processes through which you can submit a request for review. Refer to the MCOs policies for additional information.

It is our collective goal to simplify the retroactive eligibility authorization process and minimize claims denials. As part of these efforts, the MCOs are working together to further streamline processes related to deliveries, normal newborns, and neonatal intensive care unit (NICU) admissions. Additional information will be communicated in the near future.