Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you an additional $75.02 toward urgent care services you 
received in Florida on December 7, 2022, and December 9, 2022. 
 
You asked the Plan to reimburse you an additional $75.02.. You say that you received urgent care services 
while in Florida but were not reimbursed properly. The Plan denied your request. The Plan says you were 
reimbursed properly for these services. 
 
The Plan must follow Medicare rules. Medicare rules say that when an enrollee goes to an out-of-network 
provider for services, and that provider is not a Medicare-contracted provider, the Plan must pay the non-
contracting, non-participating (non-par) provider the difference between the enrollees cost-sharing and the 
original Medicare limiting charge, which is the maximum amount that original Medicare requires a Plan to 
reimburse a provider. The enrollee only pays plan-allowed cost-sharing. 
 
 In this case, you went to an urgent care center on December 7, 2022, and December 9, 2022.  For the December 
7, 2022, date of service, the urgent care provider billed the services in dispute with code 99203.  You were 
charged $149 by the urgent care center at the time of the service.  For December 9, 2022, the urgent care 
provider billed the services with code 99213.  Again, you paid the provider $149 for this service at the time of 
the services.  9You also received a COVID-19 test on December 7, 2022, but that service was reimbursed to 
you in full, and will not be discussed in this letter.) In total, you paid out-of-pocket $328.00. The Plan 
reimbursed you a total of 252.98. The difference between these two amounts is $75.02. 
 
We looked at how the Plan calculated its reimbursement rate to you. For code 99203 billed for December 7, 
2022, the Plan paid $123.67.  For code 99213 on December 9, 2022, the Plan paid $99.31.  Based on the 
Florida Medicare fee schedule that was in effect at the time of these services, these paid amounts correspond to 
the limiting charge set by Medicare for these codes.  The limiting charge is the allowed amount for services 
provided by providers that do not participate with Medicare.  As a result, we can only conclude that the Urgent 
Care Center you went to is a non-contracting, non-participating provider.  
 
According to Medicare rules, the Plan is required to pay the difference between your copayment for urgent care 
services (which is $0) and the limiting charge (which, for these two services combined, is $222.98).  This is 
exactly what the Plan has paid for these two services.  In other words, the Plan has reimbursed you for these 
services the correct amount according to Medicare rules, and the Plan is not responsible for further payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an additional $75.02. have not been met. Therefore, we decided that the Plan does not have to 
reimburse you an additional $75.02 toward urgent care services you received in Florida on December 7, 2022, 
and December 9, 2022.  
 
You do have the right to go back to the provider and request a refund for any difference between what you paid 
and the Medicare-allowed limiting charge.