Most common Remark Codes by malj

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									      Most common Remark Codes and Next Steps
A Remark Code is used to explain how the insurance company processed a
claim. The Next Steps offers advice on what a member should do when
dealing with specific codes.


B8     According to your plan, your benefits are lower because your care was
       coordinated by a non-network physician or other health care professional.
       (Refer to #1 of Next Steps)

DD     Your plan may provide you with network physicians and other health care
       professionals. Visits to network physicians or health care professionals
       generally cost less than visits to those physicians not in the network.
       (Refer to #1 of Next Steps)

D1/D2 Thank you for using a network physician or other health care
      professional. We have applied the contracted fee. The patient is not
      responsible for the difference between the amount charged by the
      physician or health care professional and the amount allowed by the
      contract. However, the patient is responsible for any deductible
      coinsurance amounts and amount over the annual benefit limits for this
      service, up to the eligible expense. (Refer to #1 of Next Steps)

UL     The amount charged represents the amounts indicated on the Medicare
       explanation of benefits and may not reflect the charge received on the
       bill. The not covered amount represents the Medicare, or physician or
       other health care provider adjustment applied to this charge. The patient
       is responsible for the difference between the Medicare allowed amount
       and the total amount paid by both plans. (Refer to #6 of Next Steps)

4C     This plan determines benefits once Medicare makes payment. If
       Medicare pays less than this plan's benefit, this plan will consider the
       difference. This plan's allowable benefits are based on the Medicare
       approved amount if the physician or provider accepted Medicare's
       assignment or on the limiting charge if they did not accept the
       assignment. The patient is responsible for the difference between the
       allowable amount and the total amount paid by both plans. The patient
       must pay any applicable plan deductibles and copays before this plan
       can pay any benefits. (Refer to #6 of Next Steps)
5    Our records show we have already processed this charge. (Refer to #2 of
     Next Steps)

29   Your plan covers reasonable charges for covered health services. The
     reasonable charge is based on amounts charged by other physicians or
     health care professionals in the area for similar services or supplies.
     Benefits are not available for that portion of the charge that exceeds the
     reasonable charge determined for this service. (Refer to #1 for Next
     Steps)

39   We will need a copy of the Medicare summary notice before your claim
     can be processed. (Refer to #3 for Next Steps)

51   the plan benefit for these services was determined by using the amount
     approved by Medicare. This physician or health care professional has
     agreed to accept that amount. The patient is responsible for the
     difference between the Medicare allowed amount and the total amount
     paid by both plans. (Refer to #6 for Next Steps)

59   The benefit for these services is based on the amount paid by Medicare.
     The patient is responsible for the difference between the Medicare
     allowed amount and the total amount paid by both plans. (Refer to #6 for
     Next Steps)

8S   Your plan does not cover this visit, consultation, evaluation and
     management, or associated expenses. (Refer to #4 of Next Steps)

9B   Your plan limits benefits for vision services and associated expenses.
     Payment is based on this limited benefit. (Refer to #5 of Next Steps)
                                    Next Steps

A Remark Code is used to explain how the insurance company processed a
claim. The Next Steps offers advice on what a member should do when
dealing with specific codes.

1. For Remark Codes B8, DD, D1/D2, 29:
Network providers offer discounts for their services. By using network providers
participants help maintain affordable health care coverage. If a network provider
is used, the “discount” is the difference between the amount charged column and
the amount allowed. Please note that some providers choose to bill at the
negotiated discount amount, which will appear in both the “amount charged” and
“amount allowed” column. This does not mean that a discount is not obtained; it
is just not reflected on the Explanation of Benefits (EOB).

When a network provider is used, the member’s co-insurance (if applicable) is
less than it would be if a non-network provider is used. Non-network providers
are paid based on Reasonable and Customary (also known as Usual and
Customary) charges for services provided in their geographic area. An area
means a county or such area as is necessary to obtain a representative cross-
section of provider charges for services.

Even when your plan does not require you to use a network provider (out-of-
network or Indemnity plans), you can obtain the discounts negotiated by
Caterpillar or UHC or its affiliates typically resulting in less out of pocket expense
to you.

Review your Explanation of Benefits carefully. If you feel the total charge, amount
allowed, plan covers, copay/deductible are inaccurate or any portion of the claim,
please contact UnitedHealthcare’s customer service at 1-866-228-4215.


2. For Remark Code 5
If you do not feel this charge has been previously processed, please contact
UnitedHealthcare’s customer service at 1-866-228-4215.


3. For Remark Code 39
A copy of Medicare’s explanation of benefits showing what Medicare has paid or
denied for these charges was missing from the originally submitted claim. Please
send a copy of Medicare’s summary along with UnitedHealthcare’s EOB showing
denial back to UHC at: UnitedHealthcare P.O. Box 740800, Atlanta GA 30374-
0800.
Review your Explanation of Benefits carefully. If you feel the total charge, amount
allowed, plan covers, copay/deductible are inaccurate or any portion of the claim,
please contact UnitedHealthcare’s customer service at 1-866-228-4215.


4. For Remark Code 8S
If after reviewing your EOB you do not feel this is correct, please refer to your
Summary Plan Description (SPD) or contact UnitedHealthcare’s customer
service at 1-866-228-4215.


5. For Remark Code 9B
If after reviewing your EOB you do not feel this is correct, refer to your Summary
Plan Description (SPD) or contact UnitedHealthcare’s customer service at 1-866-
228-4215. Vision benefits are payable every other calendar year for exam,
lenses and frame. For dependents 16 and under, exam and lenses are payable
every calendar year, and frames are payable every other calendar year. Please
check with UnitedHealthcare for the year of your last vision payment.


6. For Remark Codes UL, 4C, 51, 59
Providers can choose either to be participating Medicare providers or non-
participating Medicare providers. Those that are participating accept assignment,
i.e. they allow payment directly from Medicare based on Medicare’s approved
amounts. Those that are non-participating do not accept assignment, and the
member is responsible for the total charges billed by the provider and will then be
reimbursed by Medicare.

For those providers that participate with Medicare, the provider can only collect
payment for charges up to the Medicare approved amounts. If after reviewing
your Medicare summary EOB, you disagree with the payment made, please
contact your provider. If after reviewing your UHC EOB, you have questions
regarding the payment made, please contact UnitedHealthcare’s customer
service at 1-866-228-4215.

								
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