Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe outpatient clinic services rendered on November 8, 2019 to January 28, 2020.You asked the Plan to waive the copayments forthese services. You say that you should not have a copayment for the laboratory services.The Plan denied your request. ThePlan 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 $20 copayment for each in-network specialist visit for Medicare-covered services. Review of the file shows that you received outpatient clinic services on November 8, 2019. Per your contract with the Plan, there is a $20 copayment for eachin-network specialist visit for Medicare-covered services.This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $5.32. Given that the allowed amount was less than the $20 copayment, you have been asked to pay $5.32 for these services. The file shows that you received outpatient clinic services on November 20, 2019. You have been asked to pay a $20 copayment for these services. These services fall within the in-network specialist visit for Medicare-covered 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 outpatient clinic services on December 10, 2019. Per your contract with the Plan, there is a $20 copayment for each in-network specialist visit for Medicare-covered services.This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $3.54. Given that the allowed amount was less than the $20 copayment, you have been asked to pay $3.54 for these services.The file shows that you received outpatient clinic services on December 20, 2019; January 10, 2020; and January 14, 2020. You have been asked to pay a $20 copayment per visit for these services, for a total of $60. These services fall within the in-network specialist visit for Medicare-covered 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 outpatient clinic services on January 15, 2020. Per your contract with the Plan, there is a $20 copayment for each in-network specialist visit for Medicare-covered services.This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $6.13. Given that the allowed amount was less than the $20 copayment, you have been asked to pay $6.13 for these services.The file shows that you received outpatient clinic services on January 27, 2020 and January 28, 2020. You have been asked to pay a $20 copayment per visit for these services, for a total of $40. These services fall within the in-network specialist visit for Medicare-covered 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 copayments were applied for outpatient clinic services, not laboratory services. Therefore, we decided that the Plan does not have to waive the copayments forthe outpatient clinic services rendered on November 8, 2019 to January 28, 2020.