Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe office visits and outpatient surgical services rendered from September 6, 2019 to November 26, 2019.You asked the Plan to waive the copayments forthese services. You say that the charges are excessive.The Plan deniedyour request. The Plan says the copayment was 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 a $350 copayment for each Medicare-covered outpatient surgical service and a $45 copayment for each Medicare-covered specialist visit.The file shows that you received outpatient surgical services on September 6, 2019. Per your contract with the Plan, there is a $350 copayment for each Medicare-covered outpatient surgical service. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $106.01. Given that the allowed amount was less than the $350 copayment, you have been asked to pay $106.01 for these services.The file shows that you had a specialist office visit on September 6, 2019. You have been asked to pay a $45 copayment for these services. These services fall within the Medicare-covered specialist visit benefit category. This means that you have been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation you agreedto pay when you enrolled in the Plan.he file shows that you received a second outpatient surgical service on September 6, 2019. Per your contract with the Plan, there is a $350 copayment for each Medicare-covered outpatient surgical service. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $243.99. Given that the allowed amount was less than the $350 copayment, you have been asked to pay $243.99 forthese services.The file shows that you received outpatient surgical services on September 13, 2019. Per your contract with the Plan, there is a $350 copayment for each Medicare-covered outpatient surgical service. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $287.41. Given that the allowed amount was less than the $350 copayment, you have been asked to pay $287.41 for these services.The file shows that you received outpatient surgical services on September 20, 2019. Per your contract with the Plan, there is a $350 copayment for each Medicare-covered outpatient surgical service. This cost sharing is a contractual obligation you agreed to pay whenyou enrolled in the Plan. However, the Medicare allowed amount for these services was $106.01. Given that the allowed amount was less than the $350 copayment, you have been asked to pay $106.01 for these services.The file shows that you had a specialistoffice visit on September 20, 2019. You have been asked to pay a $45 copayment for these services. These services fall within the Medicare-covered specialist visit benefit category. This means that you have been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.The file shows that you received outpatient surgical services on September 27, 2019. Per your contract with the Plan, there is a $350 copayment for each Medicare-covered outpatient surgical service. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $287.41. Given that the allowed amount was less than the $350 copayment, you have been asked to pay $287.41 for these services.The file shows that you had a specialist office visit on September 27, 2019. You have been asked to pay a $45 copayment for these services. These services fall within the Medicare-covered specialist visit benefit category. This means that you have been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.The file shows that you received outpatient surgical services on October 4, 2019. Per your contract with the Plan, there is a $350 copayment for each Medicare-covered outpatient surgical service. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $287.41. Given that the allowed amount was less than the $350 copayment, you have been asked to pay $287.41 for these services.The file shows that you had a specialist office visit on October 4, 2019. You have been asked to pay a $45 copayment for these services. These services fall within the Medicare-covered specialist visit benefit category. This means that you have been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.The file shows that you received outpatient surgical services on October 18, 2019. Per your contract with the Plan, there is a $350 copayment for each Medicare-covered outpatient surgical service. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $287.41. Given that the allowed amount was less than the $350 copayment, you have been asked to pay $287.41 for these services The file shows that you had a specialist office visit on October 18, 2019. You have been asked to pay a $45 copayment for these services. These services fall within the Medicare-covered specialist visit benefit category. This means that you have been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.The file shows that you received outpatient surgical services on November 1, 2019. Per your contract with the Plan, there is a $350 copayment for each Medicare-covered outpatient surgical service. This cost sharing is a contractual obligation you agreed topay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $287.41. Given that the allowed amount was less than the $350 copayment, you have been asked to pay $287.41 for these services.The file shows that you had a specialist office visit on November 5, 2019. You have been asked to pay a $45 copayment for these services. These services fall within the Medicare-covered specialist visit benefit category. This means that you have been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.The file shows that you had a specialist office visit on November 26, 2019. You have been asked to pay a $45 copayment for these services. These services fall within the Medicare-covered specialist visit benefit category. This means that you have been asked to pay the correct amount based on the 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 copayments forthe office visits and outpatient surgical services rendered from September 6, 2019 to November 26, 2019.