Retro-Authorization Timelines by Payer
Published retro-authorization and retrospective-review pathways, conditions, and time windows as stated by each payer's own current materials.
Verify before you rely on any entry
Retro-authorization rules are payer-specific and plan-specific. Availability, the qualifying circumstances, and the time window differ by product and by date of service, and they change. Confirm every entry below against the payer's current published policy and the member's plan before acting on it. One payer's window never transfers to another.
An authorization for Procedure A does not cover Procedure B
An authorization for Procedure A does not automatically cover Procedure B. If the procedure changes before the service, update or amend the authorization before the claim whenever the payer allows it. If the procedure changes during surgery and Procedure B is actually performed, document the operative reason, preserve the accurate coding, and follow that payer's amendment or retrospective-review pathway within its published timeframe. Never change the claim code just to match the original authorization.
How to read this table
“Filing window” means the provider's deadline to request an authorization update or retrospective authorization/review. It is NOT the payer's decision turnaround, appeal deadline, timely filing limit, or a guarantee of payment.
These are 25 major NC payer/product lines, not a mathematically exact cross-line enrollment ranking. The selection is prioritized from the NC Department of Insurance accident/health market share and premium reports plus the current NC Medicaid health-plan roster. Retro-authorization rules vary by line of business, so each row is stated at the product level.
Payer pathways and stated filing windows
Commercial / Marketplace
UnitedHealthcare Commercial
Update / retro-auth timeline
- Authorized procedure changedNo modification or new authorization needed if the changed combination is on the UHC Prior Authorization Crosswalk Table.
- Performed procedure differsContact UHC within 5 business days after the service when the combination is outside the crosswalk (qualifying Commercial cases only).
1. Already authorized surgery/procedure (changes before or during the case)
Check the Prior Authorization Crosswalk Table first. If the changed code combination is listed on the crosswalk, no modification and no new authorization is required. If the changed combination falls outside the crosswalk, contact UHC (portal, chat, or the number on the member ID card) about the change. Qualifying Commercial procedure-change cases only — this section excludes genetic/molecular testing, BRCA, oncology, radiology, cardiology and injectable medications, and must not be applied to UMR, Medicare Advantage, Community Plan or excluded delegated programs.
2. Performed surgery differs from authorization (after the service)
If the performed procedure is outside the crosswalk, contact UHC within five business days of rendering the service. Keep the accurate performed code and submit the operative documentation explaining the intraoperative change. If notification was missed and the service was reduced or denied, the guide allows requesting clinical review with records explaining the change.
Blue Cross NC Commercial
Update / retro-auth timeline
- Authorized procedure changedNo universal published surgery-change filing window — contact the payer/delegated reviewer for the member/product/service-specific amendment or post-service review process.
- Performed procedure differsNo universal fixed window published; retrospective review only in unusual/case-specific circumstances. Verify the member product and current prior-review instructions.
1. Already authorized surgery/procedure (changes before or during the case)
Re-check the commercial code lookup and the actual approval for the changed procedure, and confirm the service, facility and delegated-review requirements directly with the plan or the delegated reviewer before the case where possible. Do not infer surgeon-only authorization responsibility.
2. Performed surgery differs from authorization (after the service)
There is no published universal retrospective window; retrospective review is available only in unusual/case-specific circumstances. Contact the plan or delegated reviewer with the operative note and medical-necessity documentation. The temporary January 2026 30-day Carelon system-issue exception is not a general rule.
Aetna Commercial
Update / retro-auth timeline
- Authorized procedure changedNo universal published surgery-change filing window — contact the payer/delegated reviewer for the member/product/service-specific amendment or post-service review process.
- Performed procedure differsNo general retro-auth cure for missed precertification; retrospective review limited to Aetna-defined circumstances. (Emergency inpatient notification within 1 business day is a separate rule, not a surgery-change window.)
1. Already authorized surgery/procedure (changes before or during the case)
Re-check the current precertification list and the member-specific requirement for the changed procedure. The 2026 list requires precertification when Aetna is primary or secondary where the service is subject to precertification, so confirm whether the changed service needs its own precertification and use Aetna's amendment/review route. Do not borrow UHC's five-business-day rule.
2. Performed surgery differs from authorization (after the service)
There is no general cure for a missed precertification. Retrospective review is available only under Aetna-defined circumstances, with clinical records supporting medical necessity. Emergency inpatient notification timing is a different rule and is not a surgery-change retro-auth window.
Sources: Aetna 2026 precertification list · Aetna retrospective review
Required documentation when the performed surgery differs
- Original authorization/reference number
- Original authorized CPT/procedure/service description
- Actual performed CPT/procedure/service
- Operative note and the documented intraoperative finding/medical necessity explaining why the procedure changed
- Date and time of surgery, and when the change was known
- Payer or delegated reviewer contacted, with the confirmation/reference number if available
- Do not alter accurate coding to match the original authorization
Do not include patient-identifying information on this page or in any public correspondence. Send documentation only through the payer's secure channels.
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