Allowed Amounts

I see a therapist that is out of network, her rate is $200/hr. (Changing is not an option). My new insurance plan amazingly has just a $1000 deductible for out of network coverage, and then 30% copay (up to the allowed amount) after that. My first claim came back as only allowing $122.61 per visit. Is it possible to make a case for this to be increased?

I read through my plan documents about allowed amounts, there are 3 sections, 1) Preferred Providers in MA, 2) Providers outside of MA with a local payment agreement, 3) Other Healthcare providers. #3 further breaks down scenarios (mostly emergency services) where I'd protected from balance billing. Then, it says:

"All Other Covered Services: For all other covered services not described above that are not protected from surprise billing by the No Surprises Act, the allowed charge is based on 150% of the Medicare reimbursement rate." It goes on in more detail for other scenarios that I don't think apply (like there not being a medicare reimbursement rate).

I looked up the medicare reimbursement rate for the billing code and my locality (https://www.cms.gov/medicare/physician-fee-schedule/search?Y=1&T=0&HT=0&CT=2&H1=90834&C=104&M=5), which is $108.98. 150% of that is $163.47. Shouldn't this be the allowable amount? Not $122.61?

submitted by /u/AnxiousSandwich7992
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