Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the bitewing x-rays (D0274), resin-based fillings (D2391), pulp cap (D3110), cleaning (D1110), periodic oral evaluation (D0120) and sales tax (D9985) provided on October 12, 2020, and December 1, 2020.
You asked the Plan to pay an additional amount for the dental services. You say that you chose to go to your long-term dentist who is out-of-network to continue your treatment there. Your provider billed you an amount that is greater than what the Plan pays for services, and you would like the Plan to cover this amount as well because you have money left in your dental benefit allowance for the year. The Plan denied your request. The Plan says these services were covered in accordance with the contract.
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, sales tax is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the sales tax (D9985) that was billed on October 12, 2020, and December 1, 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 a $0 copayment for covered cleanings, periodic oral evaluations, bitewing x-rays, resin-based fillings and pulp caps. For services provided out-of-network, you may be billed by the provider for any amount greater than the maximum allowable payment made by the Plan to the provider.
The provider billed $538 for the bitewing x-rays, fillings and pulp cap provided on October 12, 2020. The Plan's total maximum allowed charge for these services is $274. The Plan paid the full allowed $274, leaving you with a $0 copayment on the allowed amount for these services. In-network providers have agreed to be paid this maximum allowed amount and not bill plan members for additional amounts, regardless of what was originally billed. Out-of-network providers do not have this agreement. Because you used an out-of-network provider, are responsible for the difference between this amount and the provider's billed amount. ($538 - $274 = $264). The provider also billed $163 for the cleaning and periodic oral evaluation provided on December 1, 2020. The Plan's maximum allowable charge for these two services is $98. The Plan paid the full $98 maximum allowed amount, leaving you with a responsibility of $65. ($163 - $98 = $65). ($264 + $65 = $329 for the covered services (excluding the sales tax)).
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 pay an additional amount for the bitewing x-rays (D0274), resin-based fillings (D2391), pulp cap (D3110), cleaning (D1110) and periodic oral evaluation (D0120) provided on October 12, 2020, and December 1, 2020.