Scenario

I have a question about the amount my plan pays to an out-of-network provider for mental health and substance use disorder benefits. My plan appears to pay less than what they pay for my out-of-network medical/surgical benefits. I am concerned when I receive a large bill.

Where to start

Plan methods for determining what are called “usual, customary, and reasonable charges” or other methods for determining payments to out-of-network providers.

You can request information on what a plan pays to out-of-network providers and whether these amounts are based on sources such as Medicare rates or a schedule of “usual, customary, and reasonable rates” developed by a third party.

You can request information about:

  1. What percentage of these rates or fees the plan pays;
  2. Whether the plan relies on the same rates and percentages for outof- network medical/surgical benefits;
  3. Any modifications to the rates or fees when it comes to specific types of mental health and substance use disorder providers (such as psychologists or social workers); and
  4. Whether any similar modifications are imposed on specific types of medical/surgical benefits for specific providers and how they are determined.

If the plan relies on its own rates, you may request the studies or other documents that provide the basis for the payments to providers. Remember, there might be some information that you may not be able to get if the plan deems it proprietary or confidential.

When can I get these documents?

Promptly, but generally not later than 30 days after your request. Shorter time limits apply in the case of urgent care claims.