insurance coverage for group speech

[Sweetum]

I am trying to understand how my insurance company is providing me their UCR (usual and customary rates) for the group therapy that we are getting for DS who has Autism. They provider is out of network for my insurance provider. They processed the first claim and have reimbursed a really small amount of the total. And honestly, it doesn't make sense to say that that is UCR for our area (high COL). I want to appeal, but I want to be able to say that this is the going rate and quote some good sources if I can. Does someone here know where I can find such information? Thank you in advance.

[o_mom]

UCR is so hard to figure out. Many policies consider the in-network negotiated rate to be the UCR. So, even if they charge $300/hour, if the in-network providers have a contracted rate of $100/hr, that is the usual and customary. To really be able to decided what is UCR, you need to know not just what other places charge, but what they actually accept and know that typically insurance companies set the UCR at some percentile of those rates.

ETA: Found this that might be helpful if you have the CPT codes: http://www.fairhealthconsumer.org/medicalcostlookup/

[egoldber]

:yeahthat:

For OON, my plan pays 60% of UCR, which is the negotiated rate, not the amount billed.