Some health care benefit plans administered or insured by affiliates of UnitedHealth Group Incorporated (collectively “United”) provide out-of-network benefits for United’s members.
United offers different out-of-network benefit options to meet the unique needs of its employer customers and members. Customers choose which plans to offer to their employees. Not all plans include out-of-network benefits.
When reviewing a claim for payment for a service provided by an out-of-network provider, United follows the member’s benefit plan. The member’s benefit plan will explain which services are covered out-of-network. (Some services are covered only when received from a network provider.) The member’s benefit plan will also explain how an out-of-network claim should be paid.
Out-of-network benefits typically use one or more of the following reimbursement databases, benchmarks, or methodologies to establish the reimbursement amount for out-of-network claims.F91
CMS. The established and published rates and reimbursement methodologies used by The U.S. Centers for Medicare and Medicaid Services (“CMS”) to pay for specific health care services provided to Medicare enrollees (“CMS rates”). Benefit plans that use this benchmark use a percentage of the CMS rates for the same or similar service.
FAIR Health. The rate recommended by FAIR Health’s database. FAIR Health is a not-for-profit company, independent of United, that collects data for and manages the nation’s largest database of privately billed health insurance claims. FAIR Health organizes the claims data they receive by procedure code and geographic area. FAIR Health also organizes data into percentiles that reflect the percent of fees billed. For example, the 70th percentile for a certain service means 70% percent of the fees billed by providers for the same service. For additional information regarding the FAIR Health Benchmark Databases, please visit FAIR Health's website.
By following the member’s out-of-network benefit plan, the maximum amount United will pay for a service, at times, will be less than the amount billed by the out-of-network provider. Members are responsible to pay their share of the out-of-network cost share. The provider may bill the member for difference, if any, between the amount allowed for the out-of-network service and the out-of-network provider’s billed charge. If a negotiated rate or third-party discount is used, a provider may not bill the member for the difference between the contracted rate and the provider’s billed charge.
There may be times when services from an out-of-network provider are covered under the member’s in-network benefits. This may include when a member receives emergency services, when we approve an out-of-network provider when a network provider is not available, or when the member has in-network services and, in the course of treatment, receives services from an out-of-network provider without the member’s knowledge or consent. In these instances, the member’s benefit plan will provide information on the member’s cost share obligation.
In-network benefits paid to out-of-network providers typically use one or more of the following reimbursement databases, benchmarks, or methodologies to establish the reimbursement amount:
Reimbursement for out-of-network providers is subject to United’s reimbursement policies. Application of our reimbursement policies typically result in a decrease to the allowed amount. United’s reimbursement policies are generally based on national reimbursement rules and determinations, along with state government program reimbursement policies and requirements. Examples of the most common reimbursement rules include:
Our reimbursement policies can be found at UHCprovider.com/policies.