Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient services and office visit on 
February 21, 2022, to April 01, 2022. 
 
You asked the Plan to waive the copayments for outpatient services and office visit. You say that you want to 
appeal the amount being charged. The Plan denied your request. The Plan says the cost sharing you are being 
charged is correct. 
 
 
 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 $370 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges. You must pay a $45 
copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse 
practitioner or physicians assistant or other non-physician health care professionals in a specialists office (as 
permitted under Medicare rules). Covered services include consultation, diagnosis, and treatment by a 
specialist.  
 
On February 21, 2022, the provider billed the plan in the amount of $425.00. The allowed amount is $281.12. 
As the allowed amount of $281.12 is lesser than the copayment amount of $370, $281.12 applied as the 
copayment. On March 18, 2022, the provider billed the plan in the amount of $500.00. The allowed amount is 
$281.12. As the allowed amount of $281.12 is lesser than the copayment amount of $370, $281.12 applied as 
the copayment. On March 25, 2022, the provider billed the plan in the amount of $500.00. The allowed amount 
is $281.12. As the allowed amount of $281.12 is lesser than the copayment amount of $370, $281.12 should 
have applied as the copayment, however, $270.00 was incorrectly manually applied as the copayment and the 
plan paid $11.12. (Copayment amount $270.00 + plan paid amount $11.12 = allowed amount $281.12). On 
April 1, 2022, the provider billed the plan in the amount of $500.00. The allowed amount is $281.12. As the 
allowed amount of $281.12 is lesser than the copayment amount of $370, $281.12 applied as the copayment. 
On April 1, 2022, the provider billed the plan in the amount of $85.00. The allowed amount is $39.52. As the 
allowed amount of $39.52 is lesser than the copayment amount of $45, $39.52 applied as the copayment. 
$281.12 + $281.12 + $281.12 + $281.12 + $39.52 = $1,164. Therefore, results in the total cost sharing amount 
of $1,164.  
 
You have been asked to pay a $281.12 copayment for outpatient services and $39.52 copayment office visit, 
which is less than the copayment amount. Outpatient services and office visits fall within the Outpatient 
surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 
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 services and office 
visit on February 21, 2022, to April 01, 2022.