Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to reprocess the copayments for an out-of-network specialist visit, an eye exam 
including electroretinography, and a visual test. We decided that the Plan does not have to waive the 
copayments for an in-network specialist visit and ophthalmic diagnostic imaging.  
 
You asked the Plan to waive the copayments for an out-of-network specialist visit, an eye exam including 
electroretinography, a visual test, an in-network specialist visit, and ophthalmic diagnostic imaging. You say 
that these charges should be reconsidered. The Plan says that the correct copayments were applied. 
 
We decided that the Plan has to reprocess the copayments for an out-of-network specialist visit, an eye 
exam including electroretinography, and a visual test.  
 
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 $60 copayment for each Medicare-covered out-of-
network specialist visit and a $35 copayment for each Medicare-covered in-network specialist visit; a $25 
copayment for out-of-network outpatient diagnostic tests and a $10 copayment for in-network outpatient 
diagnostic tests; and a $50 copayment for each Medicare-covered out-of-network eye exam and a $35 
copayment for each Medicare-covered in-network eye exam. 
 
The Plan says you must pay a $60 copayment for an out-of-network specialist office visit, a $60 copayment for 
an eye exam including electroretinography, and a $25 copayment for a visual test. In this case, however, the 
record shows that the supervising physician is an in-network provider. We are directing the Plan to reprocess 
the claims on date of service June 9, 2020, to reflect in-network cost-sharing levels. Based on the Plan contract, 
you cannot be asked to pay more than a $35 copayment for your specialist office visit, a $35 copayment for an 
eye exam including electroretinography, and a $10 copayment for a visual test. Therefore, we decided that the 
Plan has to reprocess the copayments for an out-of-network specialist visit, an eye exam including 
electroretinography, and a visual test performed on June 9, 2020.  
 
We also decided that the Plan does not have to waive the copayments for an in-network specialist visit 
and ophthalmic diagnostic imaging. 
 
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 $35 
copayment for each Medicare-covered in-network specialist visit and a $35 copayment for each Medicare-
covered in-network eye exam.  
 
You have been asked to pay a $35 copayment each for an in-network specialist visit and ophthalmic diagnostic 
imaging. An in-network specialist visit falls within the "Physician/Practitioner services, including doctor?s 
office visits" benefit category. Ophthalmic diagnostic imaging falls within the "Vision care" 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. Therefore, we decided that 
the Plan does not have to waive the copayments for an in-network specialist visit and ophthalmic diagnostic 
imaging performed on June 22, 2020. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.