Which coverage change scenarios should be resolved in a Retro Review WQ?

• A. Primary coverage has not changed and is not responsible, patient/account merge
• B. Primary coverage changes and is responsible
• C. New patient with coverage change
• D. No coverage on file

Answer: (C)

Retro Review WQ focuses on resolving who is responsible for a claim when coverage information changes after a claim has already been submitted. The scenario that best fits this queue is when a new patient has a coverage change. In this situation, the new payer or coverage details can retroactively affect liability, so the review determines the correct primary/secondary payer and updates the record to ensure past and future claims are billed correctly. This helps prevent denials or mispayments caused by delayed or changed coverage.

If the primary coverage hasn’t changed, or if the issue involves a patient/account merge, the situation doesn’t require retroactive correction of payer responsibility and is better handled through other processes. Likewise, if there is no coverage on file, there isn’t a payer to resolve in a retro review.