UHC- Reimbursement for two out of network therapists seen on two different days

Hi there! I currently have a UHC POS and see two different therapists on two different days a week. One is more of a general talk therapist and the other does Exposure and Response prevention treatments for my OCD. On their super bills, I’m diagnosed with GAD and OCD respectively. Both are out-of-network providers (bc UHC in-network is soo bad for OCD care). I saw on several forums that my insurance would approve the cheaper one (my talk therapist) and not the more expensive one (OCD therapist). no surprise - that’s what happened! Does anyone know what I should do to appeal the denial of my OCD therapist? Has anyone had success doing this? Should I just stop trying to claim my cheaper therapist and only claim the expensive one instead? TYSM all help appreciated!!!

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What is the reason for denial listed on the EOB?

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Hi there! I’ll copy the wording from the letter below. This isn’t true for my other provider, who is also out of network. They paid half of the cost for that visit.


NI – BENEFITS FOR THIS SERVICE ARE DENIED. YOU SAW A HEALTH CARE PROFESSIONAL NOT IN YOUR PLAN’S NETWORK. BENEFITS ONLY APPLY WHEN YOU RECEIVE SERVICES FROM A PROFESSIONAL IN YOUR PLAN’S NETWORK.

HRA Remark Code Descriptions: – SERVICE EXCEEDS BALANCE AVAILABLE FROM THE CURRENT AND PREVIOUS PLAN YEARS.

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You can appeal but if they have a provider that is in network near you then they can deny the appeal since you went out of network.

Is this on a HMO?

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It’s a POS plan, so I should be able to be reimbursed for out of network providers?

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As a therapist, I see no reason why you can’t have both services covered, so yes, definitely go ahead and appeal. Just remember that insurance will base their reimbursement on what they consider “reasonable and customary,” which is usually much lower than actual costs. You’ll likely have to cover the difference through balance billing.

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Some POS plans have out of network while some do not. I would call the plan and ask them if you have out of network coverage or check your policy booklet.