Appeal a Usual and Customary or Out of Network Denials

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Usual and Customary Denials apply to plans where there is not a pre-agreed upon fee, usually associated with a non-contracted plan.  As there is no agreement on payment, the method the health plan chooses to cost contain claims payments is by using statistics of what is commonly billed in specific geographical regions and paying a percentage off of this number.  Some important things to know about Usual and Customary Denials, include:  

1. The Usual and Customary Amount varies significantly among health plans and is usually arbitrary.  Different health plans have different methods of determining what is paid. 

2. To appeal a Usual and Customary Denial you need statistical information to prove your health plan paid too low or that your physician charged too much. 

3. A Usual and Customary Denial could also be appealed with the assistance of your physician to prove that a higher reimbursement is due based on the fact that the medical procedure was more involved and detailed than normal.

How do you combat a Usual and Customary or Out of Network Payment Reduction/Denial? The following steps may help.

1. Review the denial with your policy booklet and verify that their denial is justified. If their reason for denial is unclear, call the customer service unit at the health plan for a more descriptive explanation. Record your conversation and document the name of the individual you spoke with for future reference.

2. Determine how does your health plan calculate a Usual and Customary allowable?

3. Verify that the methodology used by your health plan allows a high enough price, based on what your physician charged.

4. Were there any extenuating circumstances by your physician that would justify a higher payment? 

• Appeal the denial yourself by using one of our Appeal Letters.  Our Appeal Letters have been used by actual medical providers and provide arguments embedded within the Appeal Letter to make your case to the health plan to overturn your denial.  To review available appeal letters, click here and review the List of Available Appeal Letters related to Usual and Customary Denials.

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Health Symphony provides information as a general resource and does not guarantee any results, expressed or implied, obtained from its use.