Can you charge the patient a special fee on an exam and then give the patient a claim to send to insurance for the full UCR fees?

by Mary
(St. George Utah)

Can you charge the patient a special fee on an exam and then give the patient a claim to send to insurance for the full UCR (Usual, Customary, & Reasonable) fees?


I assume in this case the provider does not have a contract with the insurance provider. I know some providers now are charging up front for their services and letting the patient submit the claims - and all the hassles that can go with it.

This allows them to charge lower fees for their services by reducing overhead. But it sounds like your case is for a specific procedure or service.

I don’t think there is any problem with allowing the patient to file the claim as long a it doesn’t circumvent any contract the provider has with the insurance company. The insurance company will then reimburse the patient for the UCR fee(s) minus any deductibles or co-insurance according to their contract with the health insurance provider.

The patient normally files a claims using a "Medical Expense Claim" form provided by the insurance carrier - not the CMS-1500 the provider files. These can usually be found on the insurance companies website - but may require the patient to log in if they have online access - that's what I had to do to find one for our insurance carrier. They can also call their insurer and ask for a form and how/where to file it - typically just the toll-free number on their insurance card.

For example the Blue Cross medical expense claim form in our state for the patient is only one page and easy to fill out. It does require a copy of the bill or statement from the physician.

Hope this answers your question - if not please post a comment.


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