TLDR:

We have met out of pocket max through United Healthcare. My family member went thru breast cancer MRI in August at in-network providers and in-network facility. Noticed that add on code was used, instead of D code (which is typically service coverage eligible code)

What's the best course of an action here?

A little bit more description.

So a family member had mammogram. Upon the mammogram in May2023, they recommend to do MRI due to suspected mammogram results. This facility and hospital system is 13th largest provider in US according to Google bard. In Midwest region, it's a fairly well-known non-profit healthcare system.

Knowing that we have reached out to out of pocket max, we thought why not? As such, she did MRI on August on breast cancer.

In July, I reached out to both insurance and providers, all of them said "No, according to your insurance plan, you should be covered" When asking specific questions about CPT code and prior authorization, they also said "this MRI and CPT code does not require prior authorization per your policy". So it's all set to go.

Then this morning, I got a claim partially denied, most of which come from radiology service, apparently from MRI.

Looking at claim codes: the only different code I can see where it went wrong was ADD-ON Code: OJ

Typically, claim code would have been D2.

So a quick google search about this policy was available at this link:

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-reimbursement/COMM-Add-On-Codes-Policy.pdf

I glanced thru, but I am not 100% sure what this is about. Either way, this bill is something we wouldnt feel comfortable to afford as it's somewhere middle 4 figures in USD value.

My gut feeling is that this claim was billed as ADD-ON code, so it requires stricter service coverages.

So what would be my best course of an action here? I know I can reach out to hospital or insurance company, but in order to avoid ping pong game between hospital and insurance pointing fingers each other while at the end of days it's not their bills to pay only to waste my time, what information I need and what questions I need to ask them?

My response is something along if hospital can re-submit a claim using D2 code, instead of OJ code?

submitted by /u/taintmoun
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