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« Last post by PMRNC on December 08, 2017, 11:21:36 AM »
Extended Non-Network Reimbursement Program -   

Looks like it's most likely patient responsibility. There is a link however for "MEMBERS" if they want to arbitrate or dispute balance due bills.

In doing a bit more research it looks like UHC launched this a few years ago in FL, AZ, TX and Missouri.. it also looks like it's based on higher reimbursement than U&C BUT lower than if providers were participating. This means your claims were processed as OUT of network. Means you have every right to bill patient for any balance due.
« Last post by kita... on December 08, 2017, 10:43:40 AM »
Well I know for sure that these claims aren't ERISA but and I do not know if the fee was reduced because of U&C but they keep telling me that it's paid at ENRP rates? Are you familiar with ENRP?
« Last post by PMRNC on December 08, 2017, 10:20:18 AM »
Again, I'm still not seeing if it is know this is contracted or not, BUT none the less, state dept of insurance or TX state law will NOT help at all IF these claims are indeed ERISA which is federal. If they are ERISA, it is the patient's claim meaning it's up to them to make any appeal for higher benefit OR have them sign an ARF to give you the auth to file an appeal for higher reimbursement, the other option is to just bill the patient.

As for U&C, this is very difficult to explain how a carrier calculates U&C but you will NEVER know IF a charge is within U&C if a pre-determination of benefits is not done. A carrier is NOT allowed to give out the U&C amount, they are only allowed to tell you that YES your fee is within U&C or NO it's not within U&C. U&C calculations go back to the 1950's and it's outdated as heck and there are many ways to successfully appeal for higher benefit and sometimes the whole benefit. IF the fee was indeed cut for U&C, right off the bat the patient is responsible. Again, if it is ERISA you can have the patient either appeal the decision themselves OR sign an ARF and you can do the appeal.

Do you know if this is ERISA?
Do you know for fact the fee was reduced due to U&C?

If you are a PMRNC member we have some ERISA forms in our members only area (under ERISA) that may help.
« Last post by kita... on December 08, 2017, 09:51:19 AM »
Awesome explanation! Thanks!
 But I was under the impression that even without predetermination, payers have to pay according to the Greatest of Three Law for OON emergency services saying that they must pay either
-in network rates
-the usual and customary rate or;
-the Medicare rate
whichever is the highest amount between the three. But many reps for UHC claim that they pay at ENRP Rates. So it's hard to get them to adhere to this Greatest of Three rule
Coding / Re: HCPCS coding question
« Last post by Michele on December 07, 2017, 07:19:42 PM »
What insurance carrier is it?  Without knowing a bit more I would advise to contact the insurance carrier and ask them to explain the denial.  Based on the information you gave there does not appear to be any modifier issue.
New! / Re: Virtual Mental Health Company Set-Up...Question
« Last post by Michele on December 07, 2017, 07:17:14 PM »
The group needs to be credentialed and then each individual provider will be added/linked to the group.   The process for this varies from carrier to carrier.  If the provider's are already credentialed with a carrier then the group just needs to get added and then they need to link the provider to that group.  If the providers are not already credentialed then they will most likely credential the provider and then link them to the group.
New! / Re: Credentialing a New Teletherapy Company- HELP
« Last post by Michele on December 07, 2017, 07:08:23 PM »
The group can be credentialed with each insurance carrier and then each servicing provider is added or linked to the group.  This is not uncommon.  When you contact each insurance you state that you are enrolling a group.
Coding / HCPCS coding question
« Last post by PT Biller9200 on December 07, 2017, 12:40:29 PM »
I am having issues with a claim denial due to "invalid combination of HCPCS Modifiers". We are a Physical Therapy office, so we have a short list of procedure codes that we bill, and I haven't had an issue with HCPCS mods before.
ICD 10 codes are: M25.632, S52.532A
Treatment codes are:
I can't find an applicable rehabilitation HCPCS codes...
Are HCPCS modifiers based off of the Diagnosis Code?
I'd appreciate any help I can get.
New! / Re: Virtual Mental Health Company Set-Up...Question
« Last post by Jmojica on December 07, 2017, 12:11:20 PM »
Hello, your response was helpful. The advise you offered the owner........did it pertain to how to get their group credentialed with the insurance companies so the on-boarding providers just needed to attach themselves to the group or did the providers need to be individually credentialed apart from the group.

New! / Credentialing a New Teletherapy Company- HELP
« Last post by Jmojica on December 07, 2017, 12:08:56 PM »
Hello Everyone,

I hope everyone's Holiday was relaxing and will be joyful.

I need your opinion/advise/guidance.

A new Teletherpay mental health organization (NY) needs to get credentialed and asked me for help. The owner herself isn't a licensed professional but he servicing providers are licensed. How will I go about credentialing the organization as a group versus just credentialing each of her providers?

Any help you can provide would be helpful. I've googled this topic with no results.
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