All About allowed amounts

Allowed amounts are a predetermined cap that insurance puts on a service. The policy does not cover any amount over that cap. For example, you pay $5000 for global maternity, and we bill your insurance $5000, but the allowed amount is $3000. Insurance will ignore $2000 of the bill and only apply coverage to $3000.

Knowing the allowed amounts can help you determine how much your insurance will pay for a particular service. The Affordable Care Act made it a law that insurance companies must be transparent about the allowed amounts for clients seeing out-of-network providers. 

First check out your insurance portal. If you are able to request an estimate of out of network coverage this may be where you can see the allowed amounts. Use the codes listed below for the estimate.

If you do not have estimates avilable in your insurance portal, you will call/contact Member services and ask them for the allowed  amounts. Tell them that you are seeing an out of network provider and  are trying to determine your financial responsibility, which includes  balance billing. According to the Affordable Care Act they are supposed  to be transparent about how much they will pay for a covered service  before you receive the care.

First ask the rep if your coinsurance is a percentage of the BILLED amount or the ALLOWED amount for an out of network provider.

IF they say it is for the allowed amount, tell them you need the allowed amounts for an out of network provider.

CODES:

Your diagnosis code is O80 (Maternity)

You need the allowed amounts for the following CPT (Procedure/Service) codes:

59400 (global maternity)

59426 (prenatal)

59430 (postpartum)

99350 (home visits)

99215 (office visits)

99461 (newborn exam after delivery)

The  allowed amounts will be a dollar amount, not a range or percentage. If they give you a range, that is not the allowed amount. 

If the rep helping you can't tell you the allowed amounts, ask to speak to a supervisor. Be firm that per the Affordable Care Act, Transparency in Coverage laws, they are supposed to tell you the allowed amount of a covered service or item before receiving care. If they say you have to ask the provider for the amount,  tell them the provider is out of network and does not have the insurance allowed amounts.

If your insurance does not give you the allowed amounts or a place where you can see them (like on a portal), we suggest you submit a complaint to the U.S. Department of Health and Human Services. Please see below for an email we received about this issue from HHS.gov

You can also contact your State Insurance Commissioner and let them know your insurance company is not providing the out-of-network allowed amounts as required by the Transparency laws.

We submitted a question to HHS.gov about allowed amounts for our clients working with out of network Midwives and this is the response we received:

COPY OF EMAIL FROM Federal Health & Human Services:

"This is an update on your Health Plan Price Transparency inquiry. Please find our response below.
PT Case Number: 83702282011195
Status: Answer communicated to submitter

Health Plan Price Transparency case summary:  "We are an out of network provider. Is the insurance company supposed to tell their members the allowed amounts for out of network providers?
Having this information can make a big difference to the patient, since they  can calculate what may be balance billed and what will be covered.
Many  of our patients contact their insurance companies asking for the  allowed amounts, using the correct codes, but the insurance company does  not supply them. The client is not able to know what coverage to  expect, due to the nature of balance billing.
Thanks!"

Response:  The Transparency in Coverage final rules apply to group health plans  and health insurance issuers in the individual and group markets.  Providers are not required comply with the Transparency in Coverage  rules. 
Group health plans and issuers of group or  individual health insurance are required to disclose pricing information  to the public in two ways.
First, a set of machine-readable files containing the following sets of costs for items and services

• In-Network Rate File: rates for all covered items and services between the plan or issuer and in-network providers.
• Allowed Amount File: allowed amounts for, and billed charges from, out-of-network providers.

Second,  an internet-based price comparison tool (also available by phone, or in  paper form, upon request) allowing an individual to receive an estimate  of their cost-sharing responsibility for a specific item or service  from a specific provider or providers, for all items and services. This  includes the out-of-network allowed amount or any other rate that  provides a more accurate estimate of an amount a group health plan or  health insurance issuer will pay for the requested covered item or  service, reflected as a dollar amount, if the request for cost-sharing  information is for a covered item or service furnished by an  out-of-network provider; provided, however, that in circumstances in  which a plan or issuer reimburses an out-of-network provider a  percentage of the billed charge for a covered item or service, the  out-of-network allowed amount will be that percentage. We  recommend your clients log in to their member portals on their plan's  website and use the internet-based cost-comparison tool to find  personalized cost-sharing estimates. If your clients experience any difficulties with this, they can submit a complaint at https://www.cms.gov/healthplan-price-transparency/contact-us. 

Resources:
For additional questions, contact: PriceTransparencyInCoverage@CMS.hhs.gov.

Additional information is available at:
• Transparency in Coverage: https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance#Transparency
• CMS Transparency in Coverage website: https://www.cms.gov/healthplan-price-transparency

Thank you,

Transparency in Coverage Support Team
Center for Consumer Information & Insurance Oversight
Centers for Medicare & Medicaid Services
U.S. Department of Health & Human Services"