Appeals

[venkateshwfm]

UHC denied the claims as provider is OON with member plan. Rep advised to file appeal as the services were rendered for good cause, can any one help me, how to appeal and what info should be mention in appeal.

[Michele]

I'm not sure what the rep meant.  Most services are rendered "for good cause".  An out of network provider is out of network. 

In NY they have the Surprise Bill Act which allows out of network providers to have their claims processed as in network if the patient was in a network facility.  Is that the case here?

Were the services something that the patient couldn't get from a network provider?  Or were they emergency? 

There's really not enough info about what the services were to advise.

[PMRNC]

State laws on surprise medical bills don't cover ERISA group health plans. If the plan is a group health plan covered by ERISA an appeal can still be done but you need the patient to provide their SPD, sign an ARF and follow appeal guideline in their SPD. If unsure how to proceed you can bill the patient and let them appeal.