Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient rehabilitation services,
outpatient diagnostic procedures and tests, laboratory services, X-rays and does not have to waive the
coinsurance for CT scans provided from January 7, 2020, to December 21, 2020.
You asked the Plan to waive the copayments for outpatient rehabilitation services, outpatient diagnostic
procedures and tests, laboratory services, X-rays and to waive the coinsurance for CT scans. You say that you
disagree with the cost of the charges. The Plan denied your request. The Plan says the claims were processed
correctly and you are being charged the correct amount.
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
copayment for outpatient rehabilitation services, a $50 copayment for diagnostic tests completed in an
outpatient hospital facility, a $15 copayment for laboratory tests provided in an outpatient hospital facility, a
$40 copayment for X-rays and 20% coinsurance for diagnostic radiology services.
The record shows that you received outpatient rehabilitation services, outpatient diagnostic procedures and
tests, laboratory services, X-rays and CT scans provided from January 7, 2020, to December 21, 2020.
Therefore, you are responsible to pay your share of the cost-sharing charges. Please see the chart below.
Date of Service Service Allowed Amount Amount You Owe
1/7/2020 Outpatient Rehabilitation $100.06 $40
1/15/2020 Outpatient Rehabilitation $36.23 $36.23
1/22/2020 Outpatient Rehabilitation $36.23 $36.23
1/29/2020 Outpatient Rehabilitation $36.23 $36.23
2/7/2020 Outpatient Rehabilitation $36.23 $36.23
2/12/2020 Outpatient Rehabilitation $41.59 $40
5/8/2020 Outpatient Diagnostic
Test
$282.33 $50
5/20/2020 Laboratory Services $78.05 $15
7/6/2020 X-ray $135.78 $40
9/29/2020 X-ray $96.69 $40
10/19/2020 Laboratory Services $5.12 $5.12
10/30/2020 CT Scan $462.61 $92.52
12/2/2020 Outpatient Diagnostic
Test
$282.33 $50
12/21/2020 Laboratory Services $8.07 $8.07
The total amount you owe is: $525.63.
You have been asked to pay the total amount of $525.63 for outpatient rehabilitation services, outpatient
diagnostic procedures and tests, laboratory services, X-rays and CT scans. Outpatient rehabilitation services
fall within the outpatient rehabilitation services benefit category. Outpatient diagnostic procedures and tests,
laboratory services, X-rays and to waive the coinsurance for CT scans fall within the outpatient diagnostic tests
and therapeutic services and supplies 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
outpatient rehabilitation services, outpatient diagnostic procedures and tests, laboratory services, X-rays and
does not have to waive the coinsurance for CT scans provided from January 7, 2020, to December 21, 2020.