Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the outpatient hospital services rendered from November 13, 2019 to November 29, 2019. You asked the Plan to waive the copayments for these services. You say that the Evidence of Coverage says that you have a lower copayment for radiation services. The Plan denied your request. The Plan says the copayments were 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 $100 copayment per visit for outpatient hospital services. Review of the file shows that you received services at an outpatient hospital on November 13, 2019 and November 15, 2019. You have been asked to pay a $100 copayment per visit for these services, for a total of $200. These services fall within the outpatient hospital services 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. The file shows that you received services at an outpatient hospital on November 19, 2019. Per your contract with the Plan, there is a $100 copayment per visit for outpatient hospital services. However, the Medicare allowed amount for these services was $34.30. Given that the allowed amount was less than the $100 copayment, you have been asked to pay $34.30 for these services. The file shows that you received services at an outpatient hospital on November 20, 2019; November 21, 2019; November 22, 2019; and November 25, 2019. Per your contract with the Plan, there is a $100 copayment per visit for outpatient hospital services. However, the Medicare allowed amount for these services was $48.09. Given that the allowed amount was less than the $100 copayment, you have been asked to pay $48.09 per visit for these services, for a total of $192.36. The file shows that you received services at an outpatient hospital on November 26, 2019. Per your contract with the Plan, there is a $100 copayment per visit for outpatient hospital services. However, the Medicare allowed amount for these services was $82.39. Given that the allowed amount was less than the $100 copayment, you have been asked to pay $82.39 for these services. The file shows that you received services at an outpatient hospital on November 27, 2019 and November 29, 2019. Per your contract with the Plan, there is a $100 copayment per visit for outpatient hospital services. However, the Medicare allowed amount for these services was $48.09. Given that the allowed amount was less than the $100 copayment, you have been asked to pay $48.09 per visit for these services, for a total of $96.18. The total amount you have been asked to pay for these services is $605.23. 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 for the outpatient hospital services rendered from November 13, 2019 to November 29, 2019.