Common use of HOW TO FILE A CLAIM Clause in Contracts

HOW TO FILE A CLAIM. You must see a Network Physician in order to obtain Benefits. Except for Emergency Health Care Services and situations where specific Covered Health Care Services are not available from a Network provider, Benefits are not available for Covered Health Care Services provided by out-of-network providers. If services are not available from a Network provider, you must follow the instructions found under Health Care Services from Out-of-Network. Should you decide to seek services from an Out-of-Network provider, you are entitled to a good-faith estimate of the total cost(s). We develop our reimbursement policy guidelines in accordance with one or more of the following methodologies: • As shown in the most recent edition of the Current Procedural Terminology (CPT), a publication of the American Medical Association, and/or the Centers for Medicare and Medicaid Services (CMS). • As reported by generally recognized professionals or publications. • As used for Medicare. • As determined by medical staff and outside medical consultants pursuant to other appropriate sources or determinations that we accept. Following evaluation and validation of certain provider ▇▇▇▇▇▇▇▇ (e.g., error, abuse and fraud reviews), our reimbursement policies are applied to provider ▇▇▇▇▇▇▇▇. We share our reimbursement policies with Physicians and other providers in our Network through our provider website. Network Physicians and providers may not bill you for the difference between their contract rate (as may be modified by our reimbursement policies) and the billed charge. However, out-of-Network providers may bill you for any amounts we do not pay, including amounts that are denied because one of our reimbursement policies does not reimburse (in whole or in part) for the service billed. You may get copies of our reimbursement policies for yourself or to share with your out-of-Network Physician or provider at the telephone number on your ID card. We may apply a reimbursement methodology established by OptumInsight and/or a third party vendor, which is based on CMS coding principles, to determine appropriate reimbursement levels for Emergency Health Care Services. The methodology is usually based on elements reflecting the patient complexity, direct costs, and indirect costs of an Emergency Health Care Service. If the methodology(ies) currently in use become no longer available, we will use a comparable methodology(ies). We and OptumInsight are related companies through common ownership by UnitedHealth Group. Refer to our website at ▇▇▇.▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇ for information regarding the vendor that provides the applicable methodology.

HOW TO FILE A CLAIM. You must see a Network Physician in order to obtain Benefits. Except for Emergency Health Care Services and situations where specific Covered Health Care Services are not available from a Network provider, Benefits are not available for Covered Health Care Services provided by out-of-network providers. If services are not available from a Network provider, you must follow the instructions found under Health Care Services from Out-of-Network. Should you decide to seek services from an Out-of-Network provider, you are entitled to a good-faith estimate of the total cost(s). We adjudicate claims consistent with industry standards. We develop our reimbursement policy guidelines generally in accordance with one or more of the following methodologies: • As shown in the most recent edition of the Current Procedural Terminology (CPT), a publication of the American Medical Association, and/or the Centers for Medicare and Medicaid Services (CMS). • As reported by generally recognized professionals or publications. • As used for Medicare. • As determined by medical staff and outside medical consultants pursuant to other appropriate sources or determinations that we accept. Following evaluation and validation of certain provider ▇▇▇▇▇▇▇▇ (e.g., error, abuse and fraud reviews), our reimbursement policies are applied to provider ▇▇▇▇▇▇▇▇. We share our reimbursement policies with Physicians and other providers in our Network through our provider website. Network Physicians and providers may not bill you for the difference between their contract rate (as may be modified by our reimbursement policies) and the billed charge. However, out-of-Network providers may bill you for any amounts we do not pay, including amounts that are denied because one of our reimbursement policies does not reimburse (in whole or in part) for the service billed. You may get copies of our reimbursement policies for yourself or to share with your out-of-Network Physician or provider at the telephone number on your ID card. We may apply a reimbursement methodology established by OptumInsight and/or a third party vendor, which is based on CMS coding principles, to determine appropriate reimbursement levels for Emergency Health Care Services. The methodology is usually based on elements reflecting the patient complexity, direct costs, and indirect costs of an Emergency Health Care Service. If the methodology(ies) currently in use become no longer available, we will use a comparable methodology(ies). We and OptumInsight are related companies through common ownership by UnitedHealth Group. Refer to our website at ▇▇▇.▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇ for information regarding the vendor that provides the applicable methodology.