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Member Billing - Oxford Commercial Supplement, 2018 UnitedHealthcare Administrative Guide

Balance Billing Policy

Care providers in our network are contracted with Oxford to provide specific services to members. Care providers who are participating with Oxford must follow Oxford referral, precertification and privileging policies and procedures and may not bill members for unpaid charges related to covered services except for applicable copays, coinsurance, or permitted deductibles. This includes balance billing a member for a covered service that was denied by Oxford because there was no referral or authorization on file with Oxford when one was required.

Exceptions: The instances in which you are authorized to balance bill a member are listed below. (You are still required to follow Oxford’s privileging, referral and/or precertification requirements). In these instances, you may balance bill the member billed charges. To the extent that the terms and conditions of your contract conflict with these guidelines the terms and conditions of your contract shall prevail.

You may balance bill a member when:

  • A service or item is not a covered benefit (i.e., the service is excluded in the “Exclusions and Limitations” section of the member’s certificate of coverage); or
  • A benefit limit is exceeded/exhausted; or
  • Oxford denied a request for precertification, before the service was rendered, and the member proceeded to receive the service anyway; or
  • Oxford denied a concurrent certification request (i.e., the member is currently receiving the service) and you obtained the member’s signature to a clear, written statement that the service is not covered, and acknowledging s/he would be responsible for the cost of the service, before delivering the service; or
  • If you do not participate in a member’s network, and a member self refers to you (i.e., Liberty member self refers to you and you do not participate in Oxford Liberty Network). In this instance, if you participate in our W500 network, you may only bill up to your contracted rate for emergent services.

If you are uncertain whether a service is covered, you must make reasonable efforts to contact us and obtain coverage determination before seeking payment from a member. You are prohibited from balance billing the member for covered services when claims are denied for administrative reasons (lack of referral or authorization when one was required, etc.).

If a member has been inappropriately balance billed by a care provider, the member has the right to file a complaint or grievance, verbally or in writing, regarding the balance billing. Participating care providers who repeatedly violate these restrictions will be subject to discipline up to and including termination of their provider participation agreement.

If a care provider inappropriately balance-bills a member, Oxford will hold the member harmless and pursue the matter directly with the care provider.

Member Out-of-Pocket Costs

Out-of-pocket amounts for outpatient and inpatient care vary by group, type of care provider and type of benefit plan. Check the member’s health care ID for the out-of-pocket cost specific to their benefit plan.