Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for a joint injection and office visits provided from July 20, 2020, to October 1, 2020. We also decided that the Plan does not have to waive the copayment for the emergency department visit provided on October 13, 2020. We also decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) provided on November 18, 2020. We also decided that the Plan does not have to waive the copayment for the Hepatitis C test provided on November 18, 2020.   You asked the Plan to waive the copayments for the injection and office visits, emergency department visit, the MRI, and the Hepatitis C test. You say that you were unaware that you would be responsible for any costs. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $295 copayment for each outpatient surgery.   Your contract with the Plan also clearly says that you must pay a $40 copayment for each specialist office visit.  Your contract with the Plan also clearly says that you must pay a $90 copayment for emergency services.  Your contract with the Plan also clearly says that you must pay a $150 copayment for each diagnostic radiology test other than computed tomography (CT) scans.  Your contract with the Plan also clearly says that you must pay a $25 copayment for laboratory services except Hemoglobin A1c, Prothrombin (Protime), and urine Albumin.   Date of Service Procedure Copayment July 20, 2020 Joint Injection $100 ($98.59 + $1.41) August 3, 2020 Specialist Office Visit $40 August 5, 2020 Specialist Office Visit $40 October 1, 2020 Specialist Office Visit $40 October 13, 2020 Emergency Department Visit $90 November 18, 2020 Magnetic Resonance Imaging (MRI) $150 November 18, 2020 Hepatitis C Test $25 September 14, 2020 Hepatitis C Test $0 (Plan waived) Total:  $485   You have been asked to pay $100, which is less than the $295 copayment for the injection. The injection falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. You have also been asked to pay $40 for each specialist office visit.  Specialist office visits fall within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. You have also been asked to pay a $90 copayment for the emergency department visit. Emergency department visits fall within the Emergency Care benefit category. You have also been asked to pay a $150 copayment for the magnetic resonance imaging (MRI). MRI's fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. You have also been asked to pay a $25 copayment for the Hepatitis C test. Hepatitis C tests 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 a joint injection and office visits provided from July 20, 2020, to October 1, 2020. We also decided that the Plan does not have to waive the copayment for the emergency department visit provided on October 13, 2020. We also decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) provided on November 18, 2020. We also decided that the Plan does not have to waive the copayment for the Hepatitis C test provided on November 18, 2020.