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.
- Viant. A rate recommended by Viant, an independent third-party vendor that collects and maintains a database of health insurance claims for facilities, then applies proprietary logic to arrive at a recommended rate. Viant also organizes its data by percentiles.
- Negotiated Rate. The rate United or its vendors negotiate with an out-of-network provider after the service was provided. Whether a negotiated rate is available depends on the circumstances and applicable member benefit plan.
- Shared Savings Program or Third-Party Network Discounts. Sometimes United may have the right to access contracts and discounts that certain third parties have with out-of-network providers. When this program applies, the out-of-network provider's billed charges will be discounted.
- Pharmaceutical Methodology. The rate used to pay pharmaceuticals administered by a physician or other healthcare professional. Most benefit plans use a methodology that establishes the reimbursement amount based on published acquisition costs or average wholesale price for the pharmaceuticals. These methodologies are currently created by RJ Health Systems, Thomson Reuters (published in its Red Book), or United based on an internally developed pharmaceutical pricing resource. A plan may use this methodology as either the primary or secondary methodology to reimburse these services.
- Other Methodologies. These are typically used when the main methodology used by the benefit plan is not available or does not have a rate. They may include:
- a methodology established by OptumInsight or a third-party vendor that uses a relative value scale. The relative value scale is usually based on the difficulty, time, work, risk and resources of the service. We and OptumInsight are affiliated companies through common ownership by UnitedHealth Group.
- a rate based on information from a third party vendor which may reflect one or more of the following factors: 1) the complexity or severity of treatment; 2) level of skill and experience required for the treatment; or 3) comparable providers' fees and costs to deliver care.
- an amount based on the rate United pays its contracted providers for the same or similar service, adjusted as appropriate by geographic location. This may be based on the median or average rate for the contracted provider.
- a percent of the billed charges, when no other methodology is available.