Wig Benefit Reimbursement – UHC

Got an interesting one here. In 2023 UHC advertised to us during open enrollment that we would now have a $350 wig benefit for those with an alopecia diagnosis

This was of great news to our family as we would benefit from the $350 for my spouse's wig.

Called UHC and found out the closest In Network provider was in Ohio. Since we are in NC we applied for and received a GAP Exception to go out of network.

We bought the wig within the authorized out of network timeframe and paid in full then submitted a claim for reimbursement with proper receipt and documentation.

Initially it was denied because they wanted a W4 from the out of network provider. So we got UHC that form. Then it was processed using out of network benefits, paying us $0 since we haven't met OON deductible. We got them to reprocessed that since we had the GAP exceptions authorization number, even though we gave that to them the first time.

Third time should be a charm but alas now they are only giving us $166.84 of the $350 benefit amount. Wig was $538.20 and we have hit both the in network deductible and OOP Max for my spouse's.

There is no reason we shouldn't be reimbursed the full $350 benefit amount. The EOB indicates they are writing off $358.20 as a plan discount even though we went to the out of network provider and the provider never had any contact with UHC much less a pricing agreement. Calling them about this has not been fruitful. The EOB had an email address about negotiating pricing which I have sent an email requesting contact for negotiation.

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Any advice on how to proceed or what else I might be able to do?

submitted by /u/Timmyh2o