Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the services rendered to you from January 1, 2019 to June 30, 2019. You asked the Plan to waive the coinsurance for these services. You say that you had met your maximum out-of-pocket (MOOP) amount.The Plan denied your request. The Plan says the coinsurance was 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 40% coinsurance for provider and professional services at an out-of-network office, a 40% coinsurance for out-of-network lab services, a 40% coinsurance for out-of-network radiation therapy, a 40% coinsurance for out-of-network advanced imaging and basic radiological services, a $265 copayment for ground ambulance services, a $325 copayment per day for days 1-5 for in-network inpatient hospital services, a $15 copayment for in-network PCP services, and a $35 copayment for in-network specialist services, and a 40% coinsurance for out-of-network Medicare Part B covered drugs.The file shows that you received out-of-network specialist services on January 24, 2019. You have been asked to pay a 40%coinsurance for these services, for a total of $32.45.These services fall within the provider and professional services at an out-of-network office benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. The file shows that you received laboratory services on January 24, 2019. You have been asked to pay a 40% coinsurance for these services, for a total of $669.98. These services fall within the out-of-network lab services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.The file shows that you received an electrocardiogram (EKG) on January 24, 2019. You have been asked to pay a 40% coinsurance for these services, for a total of $3.51. These services fall within the out-of-network diagnostic services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.The file shows that you received an echocardiogram services on January 24, 2019. You have been asked to pay a 40% coinsurance for these services, for a total of $30.46. These services fall within the out-of-network diagnostic services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.The file shows that you received Part B drugs and a computed tomography (CT) scan on January 26, 2019.  You have been asked to pay a 40% coinsurance for these services, for a total of $1,216.70. These services fall within the out-of-network Medicare Part B drugs and advanced imaging benefit categories. This means that you have been asked to pay the correct amount based on your contract with the Plan.The file shows that you received two CT scans on January 28, 2019. You have been asked topay a 40% coinsurance for these services, for a total of $66.29. These services fall within the out-of-network advanced imaging services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.The file shows that you received specialist services on January 30, 2019. You have been asked to pay a $35 copayment for these services. These services fall within the in-network specialist services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.The file shows that you received specialist services on February 1, 2019. You have been asked to pay a 40% coinsurance for these services, for a total of $45.18. These services fall within the out-of-network specialist services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. The file shows that you received lab services on February 1, 2019. You have been asked to pay a 40% coinsurance for these services, for a total of $16.92. These services fall within the out-of-network lab services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.The file shows that you received specialist services on February 18, 2019. Per your contract with the Plan, there is a $35 copayment for in-network specialist services; however, the Medicare allowed amount for these services was $30.99. Given that the allowed amount was less than the $35 copayment, you have been asked to pay $30.99 for these services.The file shows that you received PCP services on February 27, 2019. You have been asked to pay a $25 copayment for these services. These services fall within the in-network PCP services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.The file shows that you received lab services on March 5, 2019. You have been asked to pay a 40% coinsurance for these services, for a total of $344.13. These services fall within the out-of-network lab services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.The file shows that you received two x-rays on March 5, 2019. You have been asked to pay a 40% coinsurance for these services, for a total of $8.48. These services fall within the out-of-network basic radiological services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.The file shows that you received magnetic resonance imaging (MRI) on March 14, 2019. You have been asked to pay a 40% coinsurance for these services, for a total of $42.38. These services fall within the out-of-network advanced imaging services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.The file shows that you received inpatient hospital services from March18, 2019 to March 20, 2019. You have been asked to pay a $325 copayment per day for these services, for a total of $650.These services fall within the in-network inpatient hospital services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.The file shows that you received an ambulance transport on March 18, 2019. You have been asked to pay a $265 copayment for these services. These services fall within the ground ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.The file shows that you received physician services on March 18, 2019 and March 19, 2019. You have been asked to pay a 40% coinsurance for these services, for a total of $183.42. These services fall within the out-of-network specialist services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.The file shows that you received specialist services on April 25, 2019. You have been asked to pay a $35 copayment for these services. These services fall within the in-network specialist services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.The file shows that you received PCP services on April 29, 2019. You have been asked to pay a $15 copayment for these services. These services fall within the in-network PCP services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. The file shows that you received specialist services on May 20, 2019. You have been asked to pay a 40% coinsurance for these services, for a total of $53.15. These services fall within the out-of-network specialist services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.The file shows that you received radiation therapy on May 21, 2019 to May 22, 2019. You have been asked to pay a 40% coinsurance for these services, for a total of $392.37. These services fall within the out-of-network radiation therapy benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.The file shows that you received radiation therapy on May 22, 2019 to May 24, 2019. You have been asked to pay a 40% coinsurance for these services, for a total of $1,788.83. These services fall within the out-of-network radiation therapy benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.The file shows that you received radiation therapy on May 28, 2019 to May 31, 2019. You have been asked to pay a 40% coinsurance for these services, for a total of $1,142.88. These services fall within the out-of-network radiation therapy benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.The file shows that you received radiation therapy on May 28, 0219 to June 3, 2019. You have been asked to pay a 40% coinsurance for these services, for a total of $78.47. These services fall within the out-of-network radiation therapy benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.The file shows that you received radiation therapy on May 28, 2019; June 3, 2019 to June 4, 2019; and June 5, 2019. You have been asked to pay a 40% coinsurance for these services, for a total of $34.52. These services fall within the out-of-network radiation therapy benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.The file shows that you received radiation therapy on June 10, 2019 to June11, 2019. You have been asked to pay a 40% coinsurance for these services, for a total of $531.77. These services fall within the out-of-network radiation therapy benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.The file shows that you received lab services on June 12, 2019. You have been asked to pay a 40% coinsurance for these services, for a total of $6.11. These services fall within the out-of-network lab services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.The total amount you are being asked to pay for these services is $7,743.45. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.The file does not show that you had met your maximum out-of-pocket total.Therefore, we decided that the Plan does not have to waive the coinsurance for the services rendered to you from January 1, 2019 to June 30, 2019.