Your insurance company has denied your claim for the following reasons:

• Charges exceed your contracted/legislated fee schedule
• Usual and customary reductions (UCR)

Steps you should follow to appeal insurance denials:

• Contact your insurance company to verify if Mayo Clinic is contracted and in network with your policy.
  • If yes, request that your insurance company reprocess the claim and pay per the contract with Mayo Clinic.
  • If no, did you need/obtain a referral?
    • If yes, ask your insurance company to reprocess the denied charges.
    • If no, ask your primary care physician to submit a referral authorization.
  • Was your service provided in an emergency room? If so, contact your insurance company to review your policy for emergency care coverage.
    • Request that the claim be reprocessed if you are covered as in-network for emergent care.
    • If you do not have in-network emergent care, appeal the denial with your insurance company.
      • Request a detailed itemization of the denied charge from your insurance company.
      • Request an explanation of the factors the insurance company used to determine that your charges were higher than those being charged by other providers.
      • Ask your insurance company to provide you with a list of the prices of other providers to which your charges are being compared.
      • Some states are now requiring provider pricing transparency; check the website of the provider you received care from.
      • Below are a few pricing links.
        • www.nlm.nih.gov
        • www.mnhospitals.org/data-reporting/minnesota-hospital-price-check/hospital-report
        • https://price.healthfinder.fl.gov/
        • www.healthcarebluebook.com
        • www.newchoicehealth.com

Jan. 25, 2024

Original article: https://www.mayoclinic.org/patient-visitor-guide/billing-insurance/insurance/post-service-denials/denial-reason-group-6