Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for the intraoral x-ray (D0220) and filling (D2391) provided on February 5, 2021, by an out-of-network provider.

You asked the Plan to waive the cost-sharing for the dental services. You say that you paid this bill in full and
expect additional reimbursement. The Plan denied your request. The Plan says these services were received
from an out-of-network provider and were reimbursed at the correct rate. No further reimbursement is due.

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. 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 50% coinsurance for periapical xrays
and 55% coinsurance for fillings that are received from an out-of-network provider. Benefits received outof-
network are subject to any in-network benefit maximums, limitations and/or exclusions. You may be billed
by the out-of-network provider for any amount greater than the payment made by the Plan to the provider.

Documentation shows that you paid $179 out-of-pocket for these services, and the Plan issued $67.65 in
reimbursement to you. This means that you have paid $111.35 for these services, and the Plan has determined
this is your correct share of the cost.

The provider billed $153 for the filling. The Plan's allowed amount for this service is $127. In-network
providers have agreed to accept this allowed amount as a full payment for this service, but out-of-network
providers do not have this agreement and are allowed to bill for any amount greater than the Plan's allowed
amount. ($153 - $127 = $26). In addition, the contract states that you are responsible for 55% coinsurance for
fillings received from an out-of-network provider. This percentage is taken from the Plan's allowed cost for the
service. ($127 x 55% coinsurance = $69.85). This means that you are responsible for $95.85 for the filling ($26
billed amount not covered by the Plan + $69.85 coinsurance = $95.85).

The provider billed $26 for the x-ray. The Plan's allowed amount for this type of x-ray is $21, so you are
responsible for the $5 difference between the Plan's allowed amount for this service and the amount the out-ofnetwork
provider billed. In addition, periapical x-rays received from out-of-network providers require 50%
coinsurance. ($21 x 50% = $10.50). This means you are responsible for $15.50 for the x-ray ($5 billed amount
not covered by the Plan + $10.50 coinsurance = $15.50).

The amount reimbursed by the Plan left you responsible for $111.35 of the cost for these services. ($95.85 +
$15.50 = $111.35). This means that you have been held responsible for the correct amount and no further
reimbursement is due for these services 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 cost-sharing for the intraoral x-ray (D0220) and filling (D2391) provided on February 5, 2021, by
an out-of-network provider.