Hello! Can anyone walk me through balance billing on Out of Network Claims when a clinic files to insurance? It's my understanding that my provider cannot bill me over the amount than the in network fee if submitting to insurance... So if they submit a claim that is $140 to UHC for speech services and UHC says the in network cost is not to exceed 120, they pay $80, then I would be responsible for the remaining balance of $40. Is this a correct scenario? Or am I responsible for the full $140 regardless of what my EOB says?
I'm in a situation where I have gotten prior authorization for speech services for my son starting in November of 2020 for 156 visits, out of network. The provider is filing to UHC on my behalf but are sending claims as one line item lump sum without DOS and all clinical information needed to pay the claims that would initially be submitted on a HCFA 1500. I've had to go back and resubmit each claim individually, which they are currently processing. I've paid in full out of pocket $3200 to the provider. They told me I have to pay them and then my insurance will send me a check. But, if they are filing the claims, then I would think that'd they would need to enter those EOB's into their system to show how the claims were processed and then bill me the difference for the out of network cost. Like they are ignoring there is any type of audit trail at all. Is any of this close to how I understand it? lol. Ugh.
I'm in a situation where I have gotten prior authorization for speech services for my son starting in November of 2020 for 156 visits, out of network. The provider is filing to UHC on my behalf but are sending claims as one line item lump sum without DOS and all clinical information needed to pay the claims that would initially be submitted on a HCFA 1500. I've had to go back and resubmit each claim individually, which they are currently processing. I've paid in full out of pocket $3200 to the provider. They told me I have to pay them and then my insurance will send me a check. But, if they are filing the claims, then I would think that'd they would need to enter those EOB's into their system to show how the claims were processed and then bill me the difference for the out of network cost. Like they are ignoring there is any type of audit trail at all. Is any of this close to how I understand it? lol. Ugh.
