Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay additional reimbursement for services provided from April 19, 2021,
to May 26, 2021.
You asked the Plan for additional reimbursement. You asked the Plan to reimburse $812 of coinsurance paid.
The Plan denied your request. The Plan says this coinsurance was assessed correctly. Maximus partially
overturned the Plans denial. The Plan requested a reopen and provided a full breakdown of how these services
were calculated.
You are requesting reimbursement for the coinsurance paid. In your appeal letter you state you paid $1,160.00
to the provider and that since you saw an out of network chiropractor, you are entitled to reimbursement of
70% of the amount paid since the coinsurance is 30%.
The Plan states a review of the patient ledger attached with the reopen shows that you actually only paid
$1,033.81 to the provider and you have a credit with the provider of $280.00 after all of the payments meaning
you overpaid the provider for the total amount of services that were actually received. The total amount the
Plan shows billed on the claim is $864.01 where the Plan had originally paid $85.20 to you before they
received your appeal and had the claim reprocessed. After the appeal review, it was determined that you should
be reimbursed in full, minus 30% coinsurance. The claim was reprocessed and paid to you with the $4.31 sales
tax in full ($864.01 minus $4.31 equals $859.70 times 30% equals $257.91 and $859.70 minus $257.91 equals
$601.79 plus $4.31 equals $606.10.) You were reimbursed $606.10 in total after the appeal and this what the
Plan upheld. The Plan was unable to contact you to determine if this amount was acceptable. Your appeal letter
states you should have been reimbursed $812.00. Review of a patient ledger provided by the Plan shows that
$110.20 was adjusted out and the Plan overpaid you during the initial reprocessing of the claim.
Maximus stated the Plan should have reimbursed you an additional $92.18. Maximus thought the Plan had
reimbursed you $606.10 on top of the $85.20 that was already paid to you on the claim bringing the total
reimbursed amount to $691.30. This part is incorrect, the Plan only reimbursed you a total of $606.10, however
the confusion is in the language used by the Plan on what was reimbursed. Maximus states you should have
actually been reimbursed $783.48. Maximus stated $1,119.26 was the Medicare allowed amount times 30%
equals $335.78. Maximus stated $1,119.26 minus $335.78 equals $783.48. Maximus stated $783.48 minus
$691.30 equals $92.18. Maximus is saying this leaves an amount of $92.18 that should still be reimbursed.
Since Maximus ruled on this, an additional $92.18 has been reimbursed to you. However, Maximus did not
account for the fact that the Plan had already reimbursed a total of $691.30 to you. In conclusion, the Plan
argues they overpaid you by $77.14 with the initial reprocessing of the claim after the appeal since code 35103
should not have been directly to you. The Plan argues they applied the 30% coinsurance correctly based on the
2021 Plan contract agreement.
After review of the documentation submitted, we find the Plan is correct in its argument. The rules say a plan
must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan
clearly says that you must pay 30% coinsurance for out of network chiropractic services. Based on the claim
submitted by your provider and the services rendered, you were asked to pay the correct amount based on your
contract with the Plan. Unfortunately, your overpayment to the provider and the Plans error in reprocessing the
claim caused this confusion. Also keep in mind that any overpayment directly to the provider is the providers
responsibility to correct and not the Plans. The Plan noted that you have a credit with the provider due to that
overpayment. Therefore, we decided that the Plan does not have to pay further reimbursement for out of
network therapeutic services provided from April 19, 2021, to May 26, 2021.