UnitedHealthcare won't pay all of my claim for seeing specialist - KANSAS

[AmarieNorton]

What is the name of your state? KANSAS

My insurance company only paid a small portion of my bills for a high-resolution ultrasound.

Background:
My OBGYN suspected fetal limb growth retardation of my unborn child so he sent me to see the only neo-natal specialist in town for a consult/high resolution ultrasound. This generated two claims:

Specialist charge - $389.75, patient responsibility $166.50
Facility charge - $546.15, patient responsibility $452.37

The facility is one of the two hospitals in town and happens to be the one that’s out of the network. Basically if the specialist was located elsewhere, we wouldn’t be having an issue.

I want to appeal this on the grounds that there was a “medical necessity” and based on the fact that I had no other choice than to see the specialist at his facility which happened to be located at the out of network hospital.

Does anyone have any advice on how I could fight this?What is the name of your state?

[cbg]

Unless your policy specifies that an out of network facility will be paid in full in cases of medical necessity (which is not the same thing as an emergency) they are not obligated to do so.

[sukharev]

Was it HMO? If yes, then was your doctor a primary care physician? If yes, did he do a referral? If no, maybe he could write one retrospectively.

The percentage UHC paid sounds way to low for an out-of network hospital, but maybe that's what your plan is. Mine had 80% covered.

[ecmst12]

It's also possible that your plan has a provision to pay the in-network rate to an OON specialist if there is no in-network specialist within a certain number of miles from you. So read your policy booklet. In there will also be instructions on how to appeal a claims decision.

[AmarieNorton]

Originally Posted by sukharev

Was it HMO? If yes, then was your doctor a primary care physician? If yes, did he do a referral? If no, maybe he could write one retrospectively.

The percentage UHC paid sounds way to low for an out-of network hospital, but maybe that's what your plan is. Mine had 80% covered.

Thank you for your response . The doctors office that referred me was my OBGYN, not my primary care doctor. I think I had a referral (they're the ones who urged me to go and even scheduled my appointment).

[AmarieNorton]

Originally Posted by ecmst12

It's also possible that your plan has a provision to pay the in-network rate to an OON specialist if there is no in-network specialist within a certain number of miles from you. So read your policy booklet. In there will also be instructions on how to appeal a claims decision.

Thanks for the tip !!! I'll check my booklet before I send the appeal letter.