# UHC Out of Network claims



## s_harris14 (Apr 1, 2015)

Hello!

My provider is out of network with UHC. I've noticed on a handful of claims that UHC applied a remark code of FX "This physician or health care provider is out of network. Based on an agreement with NHBC, the provider has accepted a discount for this service."

Can anyone explain what exactly this means? We did not sign any payment negotiation with UHC or a third-party. If we didn't actually accept a discount for the service, can they still slap this on the claim and apply a discount? Can we challenge this? 

TIA!


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## Bready (Apr 1, 2015)

*UHC out of network*

its been a long time since I've had experience with one of these but I think this is a repricing company who has priced the claim for payment by UHC. The repricing is the discount. Its not a PPO discount so I would definitely call UHC for clarification AND verification that having no contract with UHC your physician is under no contractual obligation to accept this payment and you can balance bill the patient the difference.
I would be interested in their explanation.  Hopefully, even with the repriced discount, you got a higher payment than if innetwork but then that's not the point is it?  Good luck.


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## KN (Apr 1, 2015)

Tia:  I believe that they may have "rented" your provider out to a network so it can reimburse at a discounted rate.  I had this happen on a few occasions to our providers.  I have attached a sample appeal letter that you can use for your situation. I obtained this appeal letter from Appeal Solutions online.    Good Luck!

Dear Director of Claims,

According to the explanation of benefits, your company appears to have reduced payment as a result of a contractual adjustment. Please accept this letter as a formal appeal of this benefit reduction.

As you are likely aware, most insurance policies or employee benefits plans fall under either state or federal disclosure laws. Most disclosure laws applicable to insurance contracts and employee benefits plans require unambiguous language related to both in and out-of-network medical treatment. As a general rule, preferred provider arrangements are coverage arrangements where the carrier applies an agreed upon discount to the benefits payments to providers who signed a contract agreeing to such discounts in exchange for ?preferred? status.

Please be advised, we do not participate in a contract with your organization and our name would not appear on any list of providers which you distribute. Further, the applicable policy or summary plan document must address how out-of-network treatment will be paid and our office must be paid according to this benefit wording rather than as an in-network provider. Typically, when no contract exists between a provider and insurer,  the claim must be paid based on reasonable billed charges rather than a discounted rate. Therefore, we must decline to accept the discount referenced on the explanation of benefits.

If benefits remain denied, please provide a detailed explanation of how the reimbursement was determined and a copy of the coverage provisions, benefits, and exclusions related to out-of-network benefits as it reads in the policy or summary plan document. This information will assist us with determining both the carrier's and the patient's liability for the remaining balance. If additional information is required from this office, please submit a written request.


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## s_harris14 (Apr 1, 2015)

Thank you both very much! I'll post an update when I have one!


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