Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-share for the services provided from February 21, 
2020 through May 15, 2020. 
 
You asked the Plan to waive the cost-share for the services. You say that you are appealing your cost-share 
responsibility for the services you received. The Plan denied your request. The Plan says the claims were 
processed accordingly with your 2019 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
The COVID-19 National Response Job Aid/ COVID-19 Exception Process does not apply as one of the 
requirements states: All services billed with COVID 19 Dx Z03.818 or Z20.828. The claims submitted did not 
have this diagnosis code/codes. 
 
You received specialist office services on February 21, March 09 and March 30, 2020, all prior to the begin 
date of waiving of cost share. In addition, for dates of service May 8 & 15, 2020 this cost share was applied to 
Part B drugs which is not eligible for this waiving of cost share. 
 
 
 
You received procedure codes 99204 (Office or other outpatient visit for the evaluation and management of a 
new patient; Typically, 45 minutes), 99213 (Office or other outpatient visit for the evaluation and management 
of an established patient; Typically, 15 minutes), 99214 (Office or other outpatient visit for the evaluation and 
management of an established patient; Typically, 25 minutes) and J9030 (BCG live intravesical instillation, 1 
mg) from an in-network provider. 
 
On February 21, 2020 for code 99204 the provider billed $482.00 and the plan paid $133.13. The Medicare 
allowable is $160.85 and you were assessed a $25.00 copayment for member responsibility. 
 
On March 9, 2020 for code 99213 the provider billed $219.00 and the plan paid $47.27. The Medicare 
allowable is $73.23 and you were assessed a $25.00 copayment to member responsibility. 
 
On March 30, 2020 for code 99214 the provider billed $319.00 and the plan paid $79.80. The Medicare 
allowable is $106.43 and you were assessed a $25.00 copayment to member responsibility. 
 
On May 08, 2020 for code J9030 the provider billed $250.00 and the plan paid $2.25. The Medicare allowable 
is $2.81 and you were assessed 20% coinsurance = $0.56 to member responsibility. 
 
On May 15, 2020 for code J9030 the provider billed $250.00 and the plan paid $2.25. The Medicare allowable 
is $2.81 and you were assessed 20% coinsurance = $0.56 to member responsibility.  
 
$25.00 + $25.00 + $25.00 + $0.56 + $0.56 = $76.12 Total member responsibility. 
 
All dates of service for claims submitted do not meet the criteria for waiving of cost share. Per the above 
benefits and guidelines, the plan's decision is correct with the original claim processing and your total 
copayment of $76.12. Cost share for specialist services and Part B drugs applied correctly. The plan is 
upholding the cost share of $76.12 as cost-sharing is a contractual obligation and cannot be waived. 
 
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This 
cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we 
decided that the Plan does not have to waive the cost-share for the services provided from February 21, 2020 
through May 15, 2020.