Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient surgery, office visits and radiation services provided from July 23, 2019 through October 29, 2019.
You asked the Plan to waive the coinsurance for outpatient surgery, office visits and radiation services. You say that you pay for Medicare and your plan. You say that the hospital should accept your insurance and pay what Medicare didn't. The Plan denied your request. The Plan says the coinsurance applied correctly.
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 for each Medicare-covered, out-of-network surgical service, 30% coinsurance for Medicare-covered, out-of-network specialist visits and 20% coinsurance for Medicare-covered, in-network therapeutic radiology services.
You have been asked to pay a total of $2,286.75 for outpatient surgery, office visits and radiation services.
Date of Service
Service
Allowed Amount
Coinsurance
Member Liability
July 23, 2019
Surgery
$1,033.96
30%
310.19
August 8, 2019
Office Visit
$204.58
30%
$61.37
August 8, 2019
Office Visit
$204.58
30%
$61.37
August 20, 2019
Radiation Management
$275.78
30%
$82.74
August 20, 2019
Radiation Treatment
$421.15
20%
$84.23
August 26, 2019
Radiation Management
$601.45
30%
$180.43
August 26, 2019
Radiation Treatment
$2,811.16
20%
$562.23
August 28, 2019
Radiation Treatment
$329.13
20%
$65.83
August 28, 2019
Radiation Management
$37.48
30%
$11.24
August 29, 2019
Radiation Treatment
$212.15
20%
$42.43
August 30, 2019
Radiation Treatment
$212.15
20%
$42.43
September 3, 2019
Radiation Management
$189.76
30%
$56.93
September 3, 2019
Radiation Treatment
$212.15
20%
$42.43
September 4, 2019
Radiation Treatment
$329.13
20%
$65.83
September 5, 2019
Radiation Treatment
$212.15
20%
$42.43
September 6, 2019
Radiation Treatment
$212.15
20%
$42.43
September 9, 2019
Radiation Management
$189.76
30%
$56.93
September 9, 2019
Radiation Treatment
$212.15
20%
$42.43
September 10, 2019
Radiation Treatment
$212.15
20%
$42.43
September 11, 2019
Radiation Treatment
$329.13
20%
$65.83
September 12, 2019
Radiation Treatment
$212.15
20%
$42.43
September 13, 2019
Radiation Treatment
$212.15
20%
$42.43
September 16, 2019
Radiation Management
$189.76
30%
$56.93
September 16, 2019
Radiation Treatment
$212.15
20%
$42.43
September 17, 2019
Radiation Treatment
$212.15
20%
$42.43
September 18, 2019
Radiation Treatment
$329.13
20%
$65.83
October 29, 2019
Office Visit
$107.03
30%
$32.11
TOTAL:
$2,286.75
Outpatient surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The office visits and radiation management services fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The radiation treatment falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. 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 outpatient surgery, office visits and radiation services provided from July 23, 2019 through October 29, 2019.