How to appeal a out-of-network denial from UnitedHealthcare

Step-by-step

1. 1

   Determine whether the No Surprises Act applies

   Emergency services, air ambulance, and out-of-network providers working at in-network facilities are protected. If any apply, the claim must be paid at in-network rates and you should be balance-billed at most the in-network cost share.

2. 2

   Request a network-adequacy exception

   If no in-network provider within reasonable distance could deliver the care, UnitedHealthcare must consider treating the claim as in-network. Gather a list of in-network providers you contacted and their wait times.

3. 3

   File the internal appeal with documentation

   Through the UHC member portal or by mail. Attach the denial, proof of network-adequacy gap, and (for emergencies) the ER record and triage notes.

4. 4

   Escalate to external review

   If UHC upholds the denial, you have 120 days to request external review. State insurance commissioners often expedite OON disputes.

Documents to gather

• Denial letter and Explanation of Benefits
• Provider's bill itemized by CPT code
• Proof of emergency or network-adequacy gap
• Records of in-network providers contacted (names, dates, wait times)

Frequently asked questions

Am I protected from balance billing?

The federal No Surprises Act protects you from surprise balance bills for emergency care and for out-of-network providers at in-network facilities. Most state laws add further protections.

What's a network-adequacy appeal?

If your plan's network can't actually deliver covered care in your area, you can ask UHC to treat an out-of-network provider as in-network. Document every in-network provider you tried.

Related denial codes

• CO-204 - Service is not covered under the patient's plan