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Updated February 6, 2002 - Health Benefits Homepage
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Frequently Asked Questions (page 3) |
| Health Benefits...Any
Questions? According to Lorraine Simpkins, PEF Health Benefits Specialist, members frequently ask the following questions about their health insurance coverage. |
| QUESTION: UHC's Reasonable and Customary (R&C) Charge is lower than what my provider charged me. How do they determine their R&C Charges and how often are they updated? |
| ANSWER: UHC uses the Health Insurance Association of America (HIAA) database to determine R&C Charges. HIAA, a health insurance trade organization, establishes R&C Charges by compiling data from actual claims. Since the R&C Charges differ depending on the geographical area where the service is performed, the accumulated data is divided into zip code areas where the providers' charges are similar. The actual charge at the 90th percentile becomes the R&C Charge. The 90th percentile charge is that amount greater than or equal to 90% of the charges for the procedure in that provider's geographic area. The R&C Charges are updated annually |
| QUESTION: What can I do if I disagree with UHC's R&C Charge? |
| ANSWER: The
member should submit an appeal to UHC to initiate a review of a claim where the provider's
fee was greater than the R&C Charge. It's possible that the information provided to
UHC was incomplete, or pertinent information was omitted. In the case of complex surgery,
for example, an operative report may not have been submitted with the claim. In these
instances, additional medical documentation may justify a greater R&C allowance. |
| QUESTION: I received an Explanation Of Benefits form indicating my claim was denied because UHC can't establish the medical necessity of my care. What should I do? |
| ANSWER: The member should contact UHC's Customer Service Department to ask what additional documentation is needed to reconsider the claim. Once s/he knows what documentation is needed, the provider should be asked to either submit the documentation to UHC, or give the documentation to the member so s/he can submit it to UHC. |