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Varying U & C for OON claims?

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thatcuteblonde:
Hi everyone!

Is anyone aware of a reason that the reasonable (or usual) and customary amount would vary within the same insurance company? My understanding is R & C amounts are based on the average billed amount by other providers of the same specialty in your geographical area. However, I have seen the 'allowed' amount range from $13.98 to $55.90 for the same service billed by the same provider/area/time frame. Sometimes it's even on the same EOB!

This happens with some of the companies that we are contracted with, though there's not much we can do about it, however for the ones that we are not contracted with, it's a pretty big discrepancy between these amounts. Anyone have any insight into this one?

Michele:
Allowed amount doesn't always mean R&C.  That is why the amounts vary within the insurance carrier.  For example our local BC has 3 different allowed amounts for the same codes, 1 for indemnity plans, 1 for PPO, and 1 for HMO's. 

If you are not contracted I would think it would be the R&C.  I would call with 2 examples and ask how the amounts are determined.

Michele

PMRNC:

Contracted = Allowed Amount
Non Contracted = U&C  or R&C

Michele:
Thanks Linda, that's what I thought but I when I went to type it I questioned myself.  I was confused (which today isn't that hard to do!) because she seemed to indicate that the amounts varied even when out of network, and that didn't make sense.

Michele

Pay_My_Claims:

--- Quote from: PMRNC on May 18, 2009, 08:37:01 PM ---
Contracted = Allowed Amount
Non Contracted = U&C  or R&C

--- End quote ---

We are non-par and we are always billed the *allowed amount/Contracted rate*. Our eob will be as follows

BCBS

Billed Charges    Contracted          Disallowed    Deductible  Copay/coins    Remaining Member exp     Amt Paid
 $6579.00         $5,765.00           $814.00       $500.00         00.00            $1314.00                     $5265.00

We as a non-par provider can just balance bill the disallowed charges to the client. I have never had a payor charge less or more simply because we were "non par"

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