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In network MRI at a Medical Center

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PMRNC:
ERISA applies for your situation so it trumps state law and payer contracts.

This one is pretty simple actually because all the other bills were paid at the network rate.

Step one is to look at your wife's SPD - This is not the same as a carriers benefit payment guide/handbook, etc, this is the actual summary plan description.
Step two - locate the appeals process (WHO you appeal to, WHERE you appeal to and how long you have to appeal)
Step three - Using the appeal process write a letter appealing their decision. Reference the other claims that were paid at the in network rate as well as attaching the EOB showing the reduced rate. (provide those EOB's and put attachments at bottom of letter referencing each one.

If you want to PM me your email address I will be happy to provide you a sample letter you can modify. I've done ERISA appeals for my own health plan and for my clients. You can also email me a copy of your EOB so I can make sure the appeal letter will line up with the benefit. Just cover my butt by blacking out all private info including dates of service. :) My email is linda@billerswebsite.com

You do not need anything from the MRI / Radiology group nor even the dr for this appeal. Under ERISA this is considered an "Adverse Benefit Determination" since they did not pay the entire fee and you are being balance billed.   

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