Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the periodic oral evaluation (D0120) and cleaning (D1110) and pay for the unspecified preventative procedure (D1999) provided by an out-of-network provider on September 8, 2020.
You asked the Plan to waive the coinsurance for the dental services and pay for the preventative procedure. You say that you tried looking for an in-network provider but were unable to find one, so you chose an out-of-network dentist. You assumed the services would be covered as in-network services, and only realized that there were several in-network providers after you contacted the Plan when you were charged your cost-sharing amount. The Plan denied your request. The Plan says out-of-network preventative dental services require 30% coinsurance, plus any charges in excess of the Plan's usual and customary rate for services. In addition, the unspecified preventative procedure is not covered by Medicare or by the Plan's supplemental dental benefit. It is your responsibility to contact the Plan prior to services to verify the network status and eligibility of providers.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested unspecified preventative procedure is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the unspecified preventative procedure provided on September 8, 2020.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 30% coinsurance, plus any amount the provider charges above the Plan's approved cost, for preventative dental services received from an out-of-network provider. You have been asked to pay $108.20 for the cleaning, evaluation, and uncovered procedure. The uncovered procedure is billed for $35, which leaves a coinsurance of $73.20 ($108.20 - $35 = $73.20) for the cleaning and evaluation together. The provider billed $195 total for these two services, but the Plan's total allowed amount for the cleaning and evaluation is $174. This means that you are responsible for $21 ($195 - $174 = $21) on top of your 30% coinsurance of the allowed amount for these services per the Plan's contract. ($174 x 30% coinsurance = $52.20. $52.20 + $21 = $73.20). These charges have applied correctly.
A cleaning and periodic oral evaluation fall within the non-Medicare covered preventative dental services category, and these services were received from an out-of-network provider. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the periodic oral evaluation (D0120) and cleaning (D1110) provided by an out-of-network provider on September 8, 2020.