Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral exam (D0140) and the filling (D2392) 
provided on September 13, 2021, and the fillings (D2392, D2391) provided on September 16, 2021, by an out-
of-network provider. 
 
You asked the Plan to pay for the dental services. You say that you did not know this provider was out-of-
network; he took over the practice from your previous provider, who was in-network. The Plan denied your 
request. The Plan says the limited oral exam is not covered by your dental benefit. You are covered for a 
maximum of two fillings per calendar year, and these have been covered at the out-of-network rate. You are 
responsible for 55% coinsurance for fillings received from an out-of-network provider, plus any amount that 
the provider bills in excess of the Plan's allowed rate for services. The third filling provided exceeds your 
frequency limitation for this service and is denied. These claims were processed correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The rules also say that a Plan 
must disclose to its employees in clear, accurate terms all cost sharing information (such as copayments, 
deductibles and coinsurance). Your contract with the Plan clearly states that you are responsible for 55% 
coinsurance for fillings performed by an out-of-network provider. You may also be billed by the out-of-
network provider for any amount greater than the payment made by the Plan to the provider.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the limited oral exam is not among 
those listed as covered under this benefit. In addition, the Plan's contract clearly states that you are covered for 
two filling procedures per calendar year. Three fillings are at issue in this case; the first two have been covered 
by the Plan and the third is denied as exceeding this frequency limitation. Therefore, we decided that the Plan 
does not have to pay for the limited oral exam (D0140) provided on September 13, 2021, and the filling 
(D2391) provided on September 16, 2021.  
 
Two of the fillings have been covered in this case. The provider billed the Plan $345 for the filling provided on 
September 13, 2021. The Plan's allowed cost for this service is $133. This is the amount that in in-network 
provider would accept as full payment for this service, but out-of-network providers do not have this agreement 
with the Plan and are allowed to bill you the difference between the billed amount and the Plan's allowed 
amount ($345 - $133 = $212). In addition, you are responsible for 55% coinsurance, which is always calculated 
from the Plan's allowed cost for a service ($133 x 55% coinsurance = $73.15). You have been asked to pay 
$285.15 for the filling ($212 + $73.15 = $285.15). This means you have been asked to pay the correct amount 
based on your contract with the Plan. 
 
The provider billed the Plan $285 for the filling provided on September 16, 2021, which was covered by the 
Plan. The Plan's allowed cost for this service is $109. You are responsible for the difference between what the 
out-of-network provider bills and the allowed cost for this service ($285 - $109 = $176). You are also 
responsible for 55% coinsurance on the allowed cost for this service ($109 x 55% coinsurance = $59.95). You 
have been asked to pay $235.95 ($176 + $59.95 = $235.95) for the covered filling provided on September 23, 
2021. This means 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 also does not have to pay any additional amount for the fillings (D2393, D2392) provided on 
September 13, 2021, and September 16, 2021, by an out-of-network provider.