Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the services rendered from November 11, 
2019 to July 16, 2020. 
 
You asked the Plan to waive the cost sharing for these services. You say that you disagree with the charges. 
The Plan denied your request. The Plan says the cost sharing 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 $90 
copayment for emergency room services, a 30% coinsurance for out-of-network outpatient surgery, and a 30% 
coinsurance for out-of-network provider and professional services. 
 
Review of the file shows that you received ER services on November 11, 2019. You have been asked to pay a 
$90 copayment for these services. These services fall within the emergency room services benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. 
 
The file shows that you received outpatient surgery at an out-of-network provider on November 26, 2019. You 
have been asked to pay a 30% coinsurance for these services, for a total of $3,456.76. These services fall within 
the out-of-network outpatient surgery benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. 
The file shows that you received specialist services from an out-of-network provider on January 28, 2020. You 
have been asked to pay a 30% coinsurance for these services, for a total of $31.49. These services fall within 
the out-of-network provider and professional services benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. 
 
The file shows that you received specialist services from an out-of-network provider on February 11, 2020. 
You have been asked to pay a 30% coinsurance for these services, for a total of $31.49. These services fall 
within the out-of-network provider and professional services benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. 
 
The file shows that you received specialist services from an out-of-network provider on June 5, 2020. You have 
been asked to pay a 30% coinsurance for these services, for a total of $31.49. These services fall within the out-
of-network provider and professional services benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. 
 
The file shows that you received outpatient surgery at an out-of-network provider on July 7, 2020. You have 
been asked to pay a 30% coinsurance for these services, for a total of $2,262.32. These services fall within the 
out-of-network outpatient surgery benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. 
 
The file shows that you received specialist services from an out-of-network provider on July 16, 2020. You 
have been asked to pay a 30% coinsurance for these services, for a total of $31.49. These services fall within 
the out-of-network provider and professional services benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. 
 
The total amount you have been asked to pay for these services is $5,935.04. 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 cost sharing for the services rendered from November 11, 2019 to July 16, 2020.