Wiki Finding Allowables if you are a non-participating office


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Hi, all............I have a couple of questions:
first a little background: i've always worked as a coder in a teaching facility doing coding for the physician side but just moved to FL and now work for a dentist (DMD) that is practicing "sleep medicine" with oral appliances (DNA, Somnodent and Moses are our 3 appliances). we are OUT OF network with ALL medical insurances because she's a DMD, not an MD. Every time we call BCBS, or UHC or any ins for that matter to find out what the patient will be responsible for since we are out of network they will tell us "we will cover xx% of the allowable", but NO INS company will give me the allowable amount. does anyone have any tricks up their sleeve on how to find this out. I've been in coding for 10 yrs, but haven't done actual billing/reimbursement in about 8 yrs so I feel as if I'm starting from scratch. And the challenge of getting a medical ins to pay a medical claim under a dentist license/NPI is a challenge in and of itself. I would greatly appreciate any and all help.
You may email me at if you'd like or post a reply here.
I'm a biller for a freestanding ASC and we are out of network (OON) with all insurances (currently). If your out of network, the insurance will not have a fee schedule. Payment is based on the patients out of network benefits. I know most of UHC plans, OON is based on a % of Medicare fee schedule. other insurance will say they pay a % of reasonable & customary, etc...

I believe the insurance will have an average allowed amount based on the contracted providers around your area. That's usually what they say is reasonable & customary, usual & customary, etc..

You may be able to negotiate with the insurances either before or after you bill the procedure for a discount % off the billed charges. Hope this help some.
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