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I work in an appeals department and currently am working on united healthcare. We have billed Emergency Department claims w/ code 99285 and charge ex: $2,000.00. UHC will only pay maybe $500.00. We know that isn't enough but when I call them and tell them that it was underpaid, the response is always they paid according to ENRP rates and they are upholding their decision. I'm starting to believe that that's just their tactic to deny reprocessing; but I need help! I just started at this job and I want to do really good!

Is the provider in or out of network?  If they are in network then they agreed to accept the fees.  If they are out of network then they can bill the patient the full balance.  I personally have not heard of getting an insurance carrier to pay more than their set fees.

These are pretty tricky. Because many don't have contracts so there's no way to see exactly what was "agreed upon." They would process and pay at in network rates but I was told there was another way to get them to pay more. I'm just trying to figure out a way to actually go about doing that .

Also we base charges off of Fair Health and Texas Department of Ins.

Well if any of these claims are ERISA, then state dept of insurance has no jurisdiction.

Next, if there is NO provider contract than carrier is applying U&C, not fee schedule as contracted.

If plan is ERISA it trumps provider contracts. Might want to try ERISA appeals on those. I would also say that you MUST know if services are contracted or not.


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