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UHC insurance

I'm wondering if anyone with United Health Care insurance has...
been denied services outside of Ohio
what are the procedures to getting treatment outside of Ohio?
Thank you
4 Responses
282113 tn?1388163349
MEDICAL PROFESSIONAL
Dear lynnet,

Whether a plan/carrier covers or denies services outside your state of residence depends on the reason why it is necessary to seek services outside your state. For instance this is not a big issue if you live close to the state line & the border town of the neighboring state has bigger & better facilities. Another example is when some providers in another state offer a course of treatment (for a condition) that is proven to have better results.

Another thing is your plan type; PPOs are more lenient with out-of-network coverage than HMOs. Most HMOs don’t even offer out of network coverage (except in a life threatening emergency situation), in or out of state. The reason behind this rule is to enable the carriers to assess the risk & potential cost of claims arising in a particular area. You may have heard of the term “USUAL & CUSTOMERY”. That just means what is the going rate for a certain service in a particular geographical area. For example the same procedure may cost $1000 in New York City, NY & only $600 in Savanna, GA. So when the carrier determines the cost of a plan in GA, they base it on the cost of potential claims in that particular area.

The bottom line is you have to make a compelling case as to why you need you access this treatment outside Ohio.

Sincerely,

Amir Mostafaie

Avatar universal
Thank you for your comments.  I don't know how to make the compelling case because my tumor is so rare (nerve sheath tumor/coxxys) most doctors are afraid to even do surgery because of nerve damage which can cause chronic pain that even pain management cannot stop or help.  I'll contact the insurance company and see what they require now. In the past years ago when I tried they said that I had to have a doctor in Ohio say that my needed treatment wasn't available in Ohio. Well it is...but when you're facing such odds you want the ones most experienced. I'll try.
I think they insurance companies should set a price they will pay and let you decide who you want to see. If the doctor accepts the payment that should be good enough.
I will as you suggested, try to make a case for it. I just don't yet know how. Thank you for your time in answering.
Lynne  
Avatar universal
I found Johns Hopkins!  and insurance didn't tell me up front but it is covered! They said no when I called but when connected at my insistance with a care coordinator I found out! YEA! Thanks!
282113 tn?1388163349
MEDICAL PROFESSIONAL
Thanks for sharing the good news and best of luck with your procedure.

Amir Mostafaie
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