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Out-of-Network Billing – Frequently Asked Questions

If you still have questions or want to get in touch with Naviguard, contact us.
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General FAQs

Naviguard works on behalf of members and their employers to resolve out-of-network medical bills with health care professionals. Learn more about what Naviguard is here.

With decades of health care experience, we are a trusted source of knowledge and advocacy, driving successful billing resolutions.

Under the No Surprises Act (NSA), effective upon the plan years beginning on or after January 1, 2022, out-of-network providers are prohibited from pursuing members directly for surprise medical bills in situations where the patient has little or no control over who provides their care. This includes all emergency services (except ground ambulances), or when an out-of-network provider is involved in their care while they are at an in-network facility. Learn more about the No Surprises Act here.

When patients choose to receive care from an out-of-network provider and the No Surprises Act does not apply, patients may still face egregious billing. Naviguard can help in certain situations. Depending on the benefits package you have, we offer full or limited advocacy models.

UnitedHealthcare members in Naviguard participating plans can call the phone number on the back of their UnitedHealthcare ID card or on the Explanation of Benefits (EOB). The UnitedHealthcare Member Services team will review the claim and transfer to Naviguard when appropriate. Naviguard will work directly with the patient on eligible claims.

Patient FAQs

Naviguard is the trusted resource for answers to patients’ out-of-network billing questions.

Naviguard services are available to UnitedHealthcare members in participating health plans at no additional cost. Patients have access to Naviguard’s advocacy and medical billing negotiation services as part of their benefits supplied by their employer.

To find out if you have access to Naviguard, call the phone number on your UnitedHealthcare ID card, or ask your employer.

If you are a UnitedHealthcare member and would like to verify your Naviguard eligibility, call the number on the back of your UnitedHealthcare ID card. Once eligibility is confirmed, contact UnitedHealthcare Member Services to get started with Naviguard. For more information on the process visit naviguard.com/patients.

To start a case with Naviguard, call the phone number on the back of your UnitedHealthcare ID card, the number on the letter you received from Naviguard, or the number on your Explanation of Benefits (EOB).

Once a Naviguard case is started, members will have direct contact with a dedicated Patient Advisor from start to finish through the Naviguard Patient Portal at my.naviguard.com.

For other inquiries, please use our online contact form here: naviguard.com/contact-us/or contact us by phone, at (866) 218-5205 (M-F, 9am-5pm CST).

Unpaid medical bills can negatively affect your credit score. Naviguard can help you resolve before it’s too late and avoid hurting your credit from unpaid medical bills. To inquire about Naviguard services call the number on the back of your UnitedHealthcare ID card.

Using an in-network health care provider may lower your costs.

Use this resource to find a provider that is in your network.*
*For UnitedHealthcare members.

Employer FAQs

Get clarity on your out-of-network billing questions so as an employer, you and your employees stay informed.

Depending on the claim and your needs, we have services ranging from self-service to full employee advocacy, all the way through arbitration resolution support. Our advisors and negotiators manage all the details and provider interactions on your behalf. Look here to learn all that Naviguard has to offer to employers.

Your employees pay nothing to utilize Naviguard’s services. Contact your UnitedHealthcare representative for more information on Naviguard’s services and associated employer pricing.

Contact your UnitedHealthcare representative for details on Naviguard, program options, and next steps to get started.

Naviguard provides balance billing advocacy support to your employees with UnitedHealthcare benefits, while helping manage out-of-network costs for both your employees and the plan.

Provider FAQs

Unresolved out-of-network billing conflicts can be costly. By engaging with Naviguard as a provider on out-of-network billing issues, you can more quickly reach resolution and get clarity on out-of-network bills, avoid arbitration, and expedite your payments.

Naviguard is a trusted source of determining appropriate out-of-network pricing for millions of health plan members. Our model and our expertise helps avoid arbitration and expedite payments. We use multiple industry pricing tools and have a highly successful negotiation track record. Healthcare providers across the country have successfully resolved their cases with Naviguard. We have engaged with over 2,000 providers across more than 170 specialties to date. Read here to learn all the reasons why, as a health provider, you should work with Naviguard.

No. Naviguard represents payors for which UnitedHealthcare is the plan administrator.

Yes. Providers can initiate the negotiation process on behalf of the patient.

Naviguard is the affiliated out-of-network advocacy service provider for the member.

Naviguard is supporting payors and ensuring that they are compliant with the rules laid out in the No Surprises Act (NSA) and that the mandatory negotiation requirement is met.

If you have submitted a formal appeal, you will need to work directly with UnitedHealthcare for the appeal process.
Contact UnitedHealthcare Member Services to obtain a status of the appeal.

For direct routing, call Naviguard’s phone number at (952) 246-0132.
Naviguard is available from 8am – 5pm CST, Monday – Friday.
Please leave a voicemail if you call outside of business hours.

No Surprises Act FAQs

The No Surprises Act (NSA) went into effect on January 1, 2022 and will have implications for patients, employers, health plans, and providers.

The No Surprises Act prohibits out-of-network providers from pursuing members directly for surprise medical bills in situations where the patient has little or no control over who provides their care. This includes all emergency services (except ground ambulances), or when an out-of-network provider is involved in their care while they are at an in-network facility. As a result, patients will be protected from surprise bills in most situations where they have little or no control over who provides their care.

However, the No Surprises Act does not apply if the member chooses to receive items and services from an out-of-network provider. The law also does not apply for ground ambulance services, or when the law’s notice and consent requirements are met for certain non-ancillary services provided at in-network facilities.

The No Surprises Act also establishes an Independent Dispute Resolution (IDR) process, also referred to as arbitration, to resolve disputes between OON providers and insurers/health plans.

Under the law, effective upon plan years beginning on or after January 1 2022, out-of-network providers are prohibited from pursuing members directly for surprise medical bills in situations where they have little or no control over who provides their care, like for all emergency services (except ground ambulance), or when an out-of-network provider is involved in their care while they are at an in-network facility.

If a patient receives a service that is covered by the No Surprises Act, the law caps the patient’s cost share to what it would be if the services were provided in-network.

Patients are protected from surprise bills when they receive:

  • Out-of-network emergency services, including air ambulance (but not ground ambulance)
  • Covered medical items and services performed by an OON provider at an INN facility (unless non-ancillary services and the provider follows the notice and consent process ).
  • Out-of-network non-emergency, ancillary services* provided at in-network facility.
  • Non-emergency, non-ancillary services provided at in-network facility, and the provider did not get your prior consent in the way the No Surprises act requires.

 

And, for the above services, your cost-share (in other words, your coinsurance, copay, deductible):

  • Is the same as it would have been if the service was provided in-network.
  • Counts toward your in-network deductible.
  • Counts toward your out-of-pocket maximum.

 

*Ancillary services include services related to emergency medicine, anesthesiology, pathology, radiology and neonatology; certain diagnostic services (including radiology and laboratory services); items and services provided by other specialty practitioners; and items and services provided by an out-of-network provider if there is no in-network provider that can provide that service.

You can find an explanation of what out-of-network laws are currently in place in your state here.

The law may not pre-empt state surprise billing laws that establish a process for determining OON reimbursement for covered items and services for insurers subject to the state’s law.

The No Surprises Act is effective for plan years when they commence on or after January 1, 2022.  Therefore, if a plan renews during 2022, the No Surprises Act will go into effect on the renewal date.

For example, if a plan year commences on December 1, 2022, the No Surprises Act will go into effect on that date.

Insurer and health plans: provisions applicable to insurers and health plans are enforced by the applicable federal agency (the Departments of Health and Human Services, Labor, and the Treasury).

Providers and facilities: provisions applicable to health care providers and facilities are enforced by the Department of Health and Human Services which may impose fines of up to $10,000 per violation.

States: provisions applicable to providers and facilities (including air ambulance) may be enforced by the states.

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