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Q: Health Care Costs for Idaho ( Answered 5 out of 5 stars,   0 Comments )
Subject: Health Care Costs for Idaho
Category: Health > Medicine
Asked by: hunter33-ga
List Price: $5.00
Posted: 22 Jan 2003 15:46 PST
Expires: 21 Feb 2003 15:46 PST
Question ID: 147207
I need to find the "reasonable and customary" charges (as defined by
Medicare standards) to perform an incision of a Thrombosed Hemorrhoid

My insurance carrier is not willing to pay the bill from my health
care provider because they claim the charge is above the reasonable
and customary charges for the area.
Subject: Re: Health Care Costs for Idaho
Answered By: voila-ga on 22 Jan 2003 17:23 PST
Rated:5 out of 5 stars
Hi Hunter,

I hope you meant that your carrier disallowed more than you expected,
rather than denying your claim for being above URC (usual reasonable
and customary).  Most carriers alter their payment rather than denying
a claim outright because it is above the reasonable charge for other
physicians in the area.

If you check on the explanation of benefits sent by your insurance
company, there should be a 5 or 6-digit code which is the CPT code. 
If it was an uncomplicated office procedure, it is probably coded


After obtaining the correct CPT code, I entered "CPT
codes+Idaho+pricing" on Google's search engine.


Once there, I found the CIGNA Healthcare Medicare Fee Schedule.  I 
downloaded the file "2003 Physician Fee Schedules" and looked up the 
code "46803" from this 56-page fee schedule document.

For participating providers in the Medicare program, the UCR is

For non-participating providers, the UCR is $181.04.

Limiting charge for this procedure is $208.20.

If you have a different 5-digit code on your explanation of benefits,
I'll be glad to look that one up for you or you can download the file
and confirm the codes yourself.  Please let me know if I can be of 
further service.

Best wishes,
hunter33-ga rated this answer:5 out of 5 stars

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