Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental cleaning (D1110) and periodic oral evaluation
(D0120) provided on May 5, 2021, and the resin-based filling (D2391) provided on June 16, 2021, by an out-
of-network provider.
You asked the Plan to pay for the dental services. You say that this provider was previously part of the Plan's
network, and you were never informed that their participation status had changed. The Plan denied your
request. The Plan says this claim was processed correctly and in accordance with your benefit. Restorations
(fillings) require 55% coinsurance when received out-of-network. In addition, you may be billed by an out-of-
network provider for any amount greater than the payment made by the Plan to the provider.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. 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 0% coinsurance for dental cleanings and periodic oral exams received from out-of-network
providers and 55% coinsurance for fillings received out-of-network. In addition, you may be billed by an out-
of-network provider for any amount greater than the payment made by the Plan to the provider.
The provider billed the Plan $149 for the cleaning and the oral exam provided on May 5, 2021. The Plan's total
allowed amount for these services is $79. This is the amount that an in-network provider would accept as full
payment for these services, but out-of-network dentists do not have this agreement with the Plan and are
allowed to bill you the remaining charges. The Plan has paid the full allowed amount for these services, leaving
you with 0% coinsurance on the allowed cost. You are being asked to pay $70 for these services, which is the
difference between what the provider billed and the Plan's allowed cost for these services ($149 - $79 - $70).
This means that you have been asked to pay the correct amount based on your contract with the Plan.
The provider billed $191 for the filling provided on June 16, 2021. The Plan's allowed cost for this filling is
$87. You are responsible for 55% coinsurance on the Plan's allowed amount ($87 x 55% = $47.85) as well as
the difference between what the provider billed and the Plan's allowed amount ($191 - $87 = $104). You have
been asked to pay $151.85 for the filling ($47.85 + $104 = $151.85). 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 pay for the
dental cleaning (D1110) and periodic oral evaluation (D0120) provided on May 5, 2021, and the resin-based
filling (D2391) provided on June 16, 2021, by an out-of-network provider.
Your complaint about a potential lack of communication regarding a change in the provider's network status is
not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by
the Plan. Medicare does not permit us to make a decision about these types of complaints.