United Healthcare Out of Network Settlement – Progress Update
June 7th, 2010. By AbiK
Ok. So one of our readers, Scott, asked a great question in his comment on my first United Healthcare (UHC) Settlement post. To paraphrase, he asked how you’re supposed to handle dependents for this settlement if you’re the policy holder and you had claims for dependents.
Hey—I’m in the same boat! And I’ve already submitted my request for my information (January 1, 2002 to May 28, 2010 only)—but under MY policy number only. Another “oh crap!”moment in this process. So here we go…
My UHC Out of Network Settlement Experience: DAY 2
Upon scanning the FAQ’s for the UHC out-of-network settlement, I see this one:
(Note: the FAQ’s are not on the unitedUCRsettlement.com website—that would be too easy; they’re over at the Claims Administrator’s website, berdonclaims.com)
Q12: I am a primary insured. Should my claim have information for the medical services and supplies I personally used, or those used by my family (myself and the dependents listed in my coverage)?
A: You need to submit one claim form for each Insurance Policy ID number. Your claim should include information for all family members covered by your policy.
Hmm. Ok. So the next question is…
What are the Insurance Policy ID numbers for all of my dependents? Do I have them? Where do I find them?
Lucky for me, I’m anal-retentive when it comes to saving files. I hate paper. I hate clutter. I love CYA (“cover your ass” for those of you in the dark on that one). So I go back to my file folder marked “medical” and retrieve some Explanation of Benefits statements.
Interesting. The only Member ID or Policy ID number shown is…mine. Even on claims for my dependents. And guess what? While I’ve saved the paper, I did not save the little plastic wallet ID cards—the ones that automatically make you feel like a “have” or “have not” more than the value on any brokerage account you hold ever could—at least in this country. Bottom line: I don’t know what the heck my dependents’ policy numbers are. At least I don’t think I do and I’m not wasting any more time digging right now.
So, I call Steve. At the Claims Administrator’s. He’s pleasant enough—but not as easy-going as Matt, who took my call last time. I can tell Steve’s got a script. And he knows little else—relative to the United Healthcare settlement, that is. He may be an out of work PhD for all I know, doing customer service to bide the time.
At any rate, I ask him…
Will I get my dependents’ information along with my own from the request form I recently sent in?
Everything I requested was under MY policy number.
Steve isn’t sure. It’s a wait-and-see thing. I should have the info by mid-to-end of June. And Steve can’t access any of those records to see if they’ve got my back on this one. However, Steve and the other folks working the lines at the Claims Administrator’s should have some access to that information by June 30, 2010 or so. So I (and you!) can call back then if I have questions. (Note, the UHC Settlement Claims Administrator’s toll-free number is: 800-443-1073; also note, claims for the UHC settlement must be postmarked by October 5, 2010—so while there is some time for this back and forth that I’m going through, time is of the essence).
Now, while I have Steve on the phone, I ask about that FAQ above—the one that says I have to fill out a claim form for each Policy ID number. That is, indeed, true. However, it depends on how my dependents are identified—ie, did we each have our own Policy ID number? I don’t know as I can’t find the blessed ID cards and it’s not clear by my Explanation of Benefits forms whether all of my dependents were merely listed under MY identification number, or whether they had their OWN numbers.
Steve’s no help on this one either. At first he seems to think that the rule-of-thumb is to submit one claim form for each settlement notice letter you’ve received. But then, upon further investigation he spits back to me the information from the FAQ above. He’s gone total script on me. I can hear him defer to—indeed cling to—that script on his screen the way someone who’s at a loss for words clings to a how-to-say-it book in order to write a condolence card. If our call were being “monitored for quality assurance”, Steve earned a check-mark today.
So here’s my take on where I am regarding my dependents:
1. I have to wait until I receive the information I’ve requested about my claims in order to know for sure if my dependents’ information has been included.
2. I should have that information by mid-to-end of June.
3. Depending on how that information is presented to me, I either have to fill out one claim form under MY Policy ID number for myself and all of my dependents, OR I will have to fill out a separate claim form for each of us based on our having different Policy ID numbers. I will have to wait to determine that.
4. If I receive the information mid-to-end of June and it only has MY claim information on it, I will have to call the Claims Administrator to determine how to a) get the claims for my dependents without my having their Policy ID numbers; and/or B) find out how to submit a claim for my dependents when I don’t have their specific claim info; That is, can I sumbit an Option Group “B” claim for myself—which would include itemized or detailed information for only me, and an Option Group “A” claim for my dependents if I have no such detailed information for them?
Are we having fun yet? Stay tuned…I’m steeped in anticipation for what awaits me mid-to-end of June!
And thanks Scott for a great question!
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I was informed that the notice number on the settlement is the key. The rep told me that many people may recieve more then one form due to address changes, member id number changes or dependent information. I am guessing the problem is that there are so many companies involved, where each had their own member id numbering system.
Hi DavidZ, Thanks for your comment–and totally agreed. I mentioned to Steve on the phone that my current health insurance carrier issues a separate card and number for each dependent (like a 5 year old needs to be carrying his own card…); but when I was with UHC, I only had one card for all dependents, and obviously myself; I'm just not recalling whether there were also separate Policy ID numbers for each of us on those cards. I've only received one notice thus far, and I'm hoping (as I'm sure most folks out there are) that I only have to fill out one claim for myself and my dependents combined, but we'll see…
Thanks for taking to the phone to get an answer for this! It's been years, and my children are now on my wife's policy (cheaper), but I want to say there was one policy number for all of us. Further delineation was by social security number, I would assume.
But, that form used to request information also asked for the social security number. I might have to just fill out one with my wife and kids' socials and see what happens.
Now if I could only find that stupid little insurance card from four years ago…
Hi Scott–I hear you! That was my problem–no clue as to where those insurance cards were, but at least I did have the statements filed away. Clearly they have records dating back to 2002, and many times your social is used when you call customer service/billing etc at a health insurance company–interchangeably with your Member ID it seems. So I'm banking on the possibility that UHC should have a trail of us all via our SS numbers as well…Good luck!
Has anyone been able to download eobs [explanation of benefits] from Pacificare when the subscriber is no longer a member?
Just wanted to add, my husband was the primary policy holder for UHC under his employer. (5 family members) When he logs into the UHC website he is able to access all dependents info except mine. Whenever I call the UHC to access info all members are under 1 SS#, that would be my husband who is the policy holder. Is this useful for anyone?
Thanks Elaine for explaining that–and it may well come in handy for some folks. Also, just another note on spouses who are the policy holders–sometimes the spouse who is the policy holder has to provide written authorization to allow the other spouse to access any of the specific insurance information–it may not apply here as in my experience this is something that’s not consistently applied, but good to be aware of.
Can you provide the website for UHC to access the eob info for pacificare?
Hi Kristi, For that one, I'm guessing your best bet is to go to http://www.pacificare.com...
I was a UHC member under both my ex-husband's policy and my own (both through employers). I received two forms…and have no idea what the policy numbers are. Will UHC willingly give these to me, even if I'm no longer a subscriber? This seems so complicated!
Hi Melissa, you should be able to get the numbers from UHC once you give them some info like your social security number, address, etc; however, my guess is that they'd be able to process your claim with even just your social security number. I've called the toll-free number for the claims administrator, and found them to be pretty helpful–that's what I'd suggest doing here. I'm sure they can point you in the right direction.
FYI… I mailed my Claims Information Request Authorization Form to Berdon Claims back when I first received my notice (late May?). I've heard nothing since. I resubmitted an electronic request, but I no longer have the Notice# from the form I was mailed. This leaves me feeling uneasy.
Question. Who does Berdon Claims work for? Is United Healthcare paying them?
Hi Joe, I'm still waiting for my information as well–for which there is a bit of a delay vs. when we were initially told to expect the information. Berdon claims is the claims administrator for the settlement; typically, the claims administrators work on behalf of the plaintiff's attorneys. So no, Berdon does not work for UHC…hope this helps!
I would like to suggest a focal person such as someone from admin on this site contact Berdon claims admin to speak for all of us requesting some sort of written confirmation even if it is email to confirm receipt of our claim request. And a update on our eob request. Especially since we all have a deadline for filing and we have to wait on them for our eob report before we can send in our certification to get our claim in the mix. Can you help us and be that focal person?
Hi Kristi, I would love to take on the role of "focal person" as you describe it, however, the type of information you're seeking–ie, confirmation of each claimant's claim and request for eob information–is really something that needs to come from the claims administrator directly upon request from each claimant; it's a bit of a privacy thing. More generally speaking, I did reach out to Berdon (the claims administrator) and the EOB info many of us requested –which was initially anticipated to be mailed out to us sometime in late June–is now to be expected in early August–so keep an eye on your mailbox. If you receive the info early August, that should still allow approximately two months before your claim is due (Oct. 5th).
On the form there is "adjusted bill date" and "adjusted bill amount" where do I find this information? I have my EOB, but do I need some other paperwork?
Hi Jolene, The EOBs don't have "adjusted bill date" and "adjusted bill amount" as you've seen–and those fields, while included on the form I received upon request for info from UHC, are blank–so I have no info to supply them with for these either. I was intending on leaving them blank–but if you'd like to check to be sure, I'd call the 800 number for Berdon (try 800-443-1073)–the claims administrator–and ask there.
In response to Jolene's question on adjusted bill date, the eob usually has a date on the top or bottem of it. That would be the adjusted date the insurance would list as the date for all dates of service on the eob. If you see more than one charge listed on the eob the date on the eob would cover all charges listed on the eob. I used to work in the insurance billing so this part makes sense.
I found an old United Healthcare card from 2002. What I see is a member # (which is the same as my SS# with a couple digits added on), a group # and an electronic claims payer id #. There's no "Insurance Policy ID" field. Does everyone agree insurance policy ID is the same as member #? Also, it strikes me as odd that the member # was simply the primary subscriber's SS#.
Hi Darren, Your member ID is usually the one you'll need–it's the ID that most specifically identifies YOU as the member in the plan. While I haven't seen the practice in a while, I can remember a time when social security numbers were used as ID numbers, with the addition of some numbers so it may not be as odd as it seems. You can certainly call the claims administrator (number is in the post above) but I'm using my group and member IDs to submit the claim.
Three of my immediate family had Golden Rule policies during the period of the proposed settlements. I have four questions.
1. Only two of the three of us received packets. I assume the third individual can simply download or copy the forms and submit them?
2. The two who received packets probably can do better as Group B subscribers than as Group A. Does each "Service received" entry on the Group B claim chart have to be from an out-of-network provider, and how do we determine that? (For one of the individuals, we actually only find two Explanation of Benefits documents on which the "covered" amount does not match the "total charged" amount OR the "repriced amount". Am I correct in assuming that those two providers are out-of-network? We recall that one of them almost certainly WAS out of network, because when we scheduled the treatment we were told they were IN network, but when they billed us they said they had advised in error, and that they were NOT in network. My next question shows our possible claim chart entry for that charge.)
3. Following is our proposed line entry for that one charge. What do we enter for the "Adjusted Bill Date" and "Adjusted Bill Amount" since the bill was never actually adjusted? (We paid the full amount.) The Explanation of Benefits document date was 06/28/2001:
Date of Service: 06/11/01
Name of Provider: Jones MD
Name of Patient: Jane Doe
Original Bill Amount: 1200.00
Allowed Amount: 250.00
Adjusted Bill Date: ??
Adjusted Bill Amount: ??
Paid Portion of Bill: 950.00 (?)
On the Explanation of Benefits, the remark code for the $1200/$250 item was remark code 01 – "This charge exceeds the reasonable and customary charge for this service."
4. Is the Explanation of Benefits sufficient documentation for the claim? We did not keep the physician's actual bill.
Hi Henry, I'm going to try to answer your questions as best as possible, but keep in mind, I'm not the "authority" on this–so you may want to follow up with the claims administrator (Berdon–they're number is on the claim form you received and also in the above post).
First off, yes, you can obtain a UHC out of network settlement claim form by downloading it–for anyone who qualifies as part of the class for this lawsuit–even though they may not have received the notice in the mail.
In terms of your next questions, yes, each claim (ie, line item) you submit does need to be for an out of network service provider. The lawsuit is expressly about out of network charges.
I would not assume from the information you've provided here in your #3 that this doctor was out of network. What you've provided here simply shows the reasonable and customary charge that UHC determined was sufficient for the service you received. That would be the $250.00. What they're saying is that they allowed $250.00 to be covered (or included in your deductible) based on what they determined to be the reasonable and customary charge. Meaning, that you would be left responsible for the remaining $950.00 unless you either fought the amount with the insurance company or tried to work out a reduced payment with your provider.
Typically, when a provider is out of network, the charges for that provider should be delineated from those that are in-network on your Explanation of Benefits (EOB). So you should see either a secton on your EOB that states your year to date amounts applied to both your in-network and out-of-network deductibles; or you'll see a code–like the remark code you saw for reasonable and customary charges only it will state that your provider is out of network (sometimes, conversely, the insurer will code a charge and say "thank you for choosing an in-network provider"–so if you don't see that remark code it could be a tip-off that the provider was out of network); or, you may be able to glean from you EOB that a provider was out of network if the EOB states the percentage of the amount they're covering. For example, some of my EOBs state that a given charge is covered at 90%–those are clearly "in-network" because the plan is covering them at a high rate. If I see a charge covered at say, 70%, it's usually a tip-off that the provider was out of network.
If you have your providers' names, and are not sure from the EOB whether they were in or out of network, you may also want to try to contact them to find out if they were accepting your health plan at the time of the date of service–you may also luck out and find that they can send you a copy of your statement–no guarantee, but worth a try.
Which brings me to your final question–yes, you need to provide documentation that you paid the remaining (ie, not covered) part of the out of network charges. That means…copies of cancelled checks, credit card statements, paid receipts from providers…etc… I know many–heck, most–folks out there do not seem to have saved all that documentation, but the best anyone can do is to submit what they have and see where things net out.
I hope this helps a bit, but don't hesitate to contact the claims administrator as well with any questions.
I contacted the claims administrator. Due to the fact that they will require proof of payment, which we no longer have, we will file under Group A. (We were also unable to resolve the out-of-network question for the two providers in question, so that was additional reason to file under Group A.)
Thank you very much for your assistance.
You're very welcome, Henry! And thanks for sharing what you found out from calling the claims administrator!