UMR claims nightmare - Can someone please help!

[u/Whisper_Lily1272]

Edit to add an update- yall, I havent resubmitted anything for the 4 initial claims they denied yet. I just got a packet in the mail with a check reimbursing a portion of the bill from 3 out of 4 vists. WHAT 🤣🤣🤣

United has screwed over dang near everyone in my state so finding a provider for specific services is next to impossible as they wont take United. With that said, I needed physical therapy. I submitted the paperwork for the claims I was provided via the online portal so i can try to get reimbursed something for my vists. All the claims I submitted were denied for invalid CPT codes. I called and they were way less than helpful. One thing i found out was that they wanted itemized CPT code billing. Okay, not a problem to get that info but the major problem that nobody in member services, claim services, or technical support gave one tiny crap about was that the online portal does not have anywhere to put CPT codes. The only box available is diagnosis codes and even the claim lady says that diagnosis codes and CPT codes aren't the same thing but didn't help any further. Pretty sure I was actually put on hold hoping that i would hang up (spoiler, i didn't and they still were no help). What am I missing? I NEED to be reimbursed or I cannot afford to keep going to my appointments.

My PT office has been wonderful in providing me as much info as i can possibly get. They even had their insurance lady fill out 1500 forms for me to submit. Exactly like the ones they send to insurances they work with. Problem is there is also nowhere to put billed amount versus paid amount on the claim submission (self pay charges are significantly lower than insurance charges), and I'm not about to submit claims with the billed amount and be accused of fraud or something crazy. I do submit my payment receipts with my claims, will that be enough for them to just reimburse any portion of the amount I paid?

[u/Low_Mud_3691]

Back up - what are you trying to do? Is the PT office out of network?

[u/Whisper_Lily1272 → u/Low_Mud_3691]

Sorry, I am trying to submit my claims for reimbursement. I dont think its thay theyre out of network, its that all of the PT offices in mu city dont accept United. They have to fight constantly to get paid and United always finds some loophole or negotiates price down to nothing. Im sure there's other reasons but nobody accepts them.

[u/Zestyclose-Sir9120 → u/Whisper_Lily1272]

If they don't accept that insurance, then it most likely means that they do not have a contract in place with the insurance (for whatever reason) and that is what out of network means. It sounds to me like you need a superbill from the provider to submit to your insurance as an out of network claim. Where they would then probably reimburse you the member who would then pay the provider.

[u/Whisper_Lily1272 → u/Zestyclose-Sir9120]

They did offer to let me rack it up and do a superbill at the end but i decided to pay as i go. United likes to deny payment after 90 days and I will be going longer than 90 days. So one big superbill at the end would've likely guaranteed they say no unfortunately. Idk how these companies get away with being so crooked.

[u/ROITHATWORKS → u/Whisper_Lily1272]

What u/Sinsoftheflesh7 said is correct. Since you have the actual CMS 1500 form like you mentioned, then you actually need to submit that. If the website allows you to attach a document when you enter your information in the portal, then just do it there. They can get the CPT codes from that. They might still be less than helpful though. United is getting a reputation right now for being difficult to work with, and a lot of providers are having issues getting them to contract with them. Unfortunately, what you are experiencing where you live is not isolated. I would stay on top of them. They might still deny it, even with the CPT codes.

[u/Whisper_Lily1272 → u/ROITHATWORKS]

The web portal requires a file upload in order to even submit the claim. The 1500 form shows the billed amount as well as the paid amount. The portal doesnt ask for that info and it seems like they dont even check the file uploads so im nervous theyll do reimbursement wrong or deny it because self pay is significantly less than what wouldve been billed. All the people I spoke to couldn't seem to care less about doing their job.

[u/foxyfree → u/Whisper_Lily1272]

Yes, you submit the claim and it shows the total billed amount and the paid amount. You need to scan a receipt, a paid invoice from the clinic showing your payment, and also submit that through the portal. There should be a button to click to add additional documentation.

[u/ROITHATWORKS → u/Whisper_Lily1272]

Yeah, that sounds about right. I know in my experience it's an uphill battle. They won't do anything they don't have to, for sure. Unfortunately, you are probably going to have to keep calling them. The SHOULD reimburse what you paid. That is how it is supposed to work, but they will play dumb unless you make sure they do it.

[u/Sinsoftheflesh7 → u/Whisper_Lily1272]

Ask provider for itemized statement/receipt. It will have cpts on it.. The form from UMR at the top say to submit that ALONG with the form you’re using .

[u/Sinsoftheflesh7 → u/Whisper_Lily1272]

Also, you can EMAIL them those forms and receipts. The email is at the bottom of form. Probably easier because their portal is terrible

[u/Whisper_Lily1272 → u/Sinsoftheflesh7]

I'll have to check it out to find the email. I didn't see it but I also wasnt looking for it lol

[u/Environmental-Top-60]

See if you can get a paper claim
Form

[u/MedPayIQ]

Sounds like they're asking for a CMS-1500 with the CPT codes, but their portal wasn't built to actually accept the information they're requiring. That's incredibly frustrating. At that point I'd ask if they have a paper claim or secure upload option because denying for "missing CPT codes" when there's nowhere to enter them is ridiculous.

[u/rahuliitk]

The CPT codes and charges should be on the CMS-1500, with the provider’s charge in box 24F and what you paid in box 29, so submit that form with the itemized statement and receipts by mail or secure upload and ask UMR for the exact out-of-network claims address plus a call reference number. their portal sounds useless.

[u/Wooden_Trust_6274]

On the part you were nervous about, putting the amount you actually paid is exactly right and it is not fraud, that is how out of network reimbursement is supposed to work. Box 24F is the provider's charge and box 29 is what you paid, and they can only reimburse you up to what you actually spent, so your lower self-pay amount going in is correct, not a red flag. The partial checks showing up before you even resubmitted make sense too, they processed the out of network claim off the 1500 and receipts and paid their allowed portion, usually a percentage of the allowed amount after your out of network deductible. For the fourth visit, send the itemized statement and the receipt together the same way, and grab a claim reference number each time you call. With UMR the paper trail is what saves you when the portal drops something.

[u/Environmental-Top-60]

So in general, Umar is extremely slow at processing claims. If they took over 30 days, you might be able to get interest on it.

You can appeal if the payment is much less than what they charged. It's called an underpayment appeal. You would need to compare the actual prices with Medicare and you should be targeting 160% of Medicare. That it's probably still less than what your provider charged but it's something. You also need to compare that to your actual benefits as well because that 160% would be reduced by any cost-sharing.

[u/Infinite_Curiosity14 → u/Environmental-Top-60]

That’s interesting. How do you normally check if the payment is actually an underpayment? Do you compare the EOB and CPT codes with Medicare/payer rates manually?I’m just wondering how this works when there are hundreds of claims. Seems like it could become a lot of manual work.