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Insur stated facility in network when not

In Febuary I saw a UHC in-network neurologist.  She sent me for an MRI.  I told the office I needed to go in-network for it.  They called later and stated “We called UHC and no pre-auth is required”.  Knowing how things work I called UHC and asked if the facility where they were sending me was in-network.  They said it was.  I had the MRI and now learn the facility is out of network and we owe $1000 (deductible since out of network).  We are now on our 2nd appeal with UHC.  In the appeal we will relay the above and note that they (UHC) admit that they have a “provider search” call logged on the day I made the appointment for the MRI (getting letter from facility verifying date appointment was made).  However, UHC states they do not note what doctor or facility was searched during the logged call.  We are also citing the UHC policy that states “Participating providers must refer patients to an in-network facility unless, after full disclosure, the patient wishes to go to the out of network facility”.  We have a copy of the MRI order from the neurologist’s office where the office staff noted “Pending per patient consent out of network facility”.  I was never informed that the facility was out of network by the neurologist’s office, nor the MRI facility.  Do you think we stand a chance of winning the appeal with the insurance company (UHC) and if not, could either the doctor’s office or MRI facility possibly be sued in small claims court?    Thank you SO much for any advice you might have.  Nancy
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282113 tn?1388159749
MEDICAL PROFESSIONAL
Dear sassy1785,

It is difficult to forecast the outcome of your appeal at this stage!
Below is some more pertinent information that can help you with the process;
- Does UHC record customer service calls? (Some Carriers record all customer service calls)
Is there a UHC contracted facility in the area & why did your Doctor's office choose the out-of-network one?
Was this facility ever in UHC network in the past?
If this facility was in-network at some point, when did it drop contract & why?
Why did your Doctor choose the facility to get your test done instead of an in-network facility?
Is there another facility with the name similar to the facility you used & is it possible that the UHC operator misunderstood your inquiry & based on that gave you wrong info?
Is there more than one UHC network in your area & is it possible that the UHC rep looked up the wrong network?
About the note logged in your account regarding your call; was it made by a fairly new representative? (New reps are more likely to make mistakes)

In my experience all of these facts could help you make a stronger case.

Wish you best of luck,

Amir Mostafaie


Helpful - 1
172023 tn?1334672284
This happened to me once.  A doctors office told me they were UHC, and it turns out they were only "pending" UHC providers (had applied to be UHC providers, not approved yet), so UHC refused that claim, and also would not cover a cardiac echo that doctor ordered.

On appeal, I demonstrated that any in network doctor would have ordered the same testing, and it was eventually approved.
Helpful - 0
Avatar universal
Many of your questions were relevant and we will definitely work more info into our appeal based on them!!  I do believe it will strengthen our case!  Thank you so much.   Nancy
Helpful - 0

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