Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the laboratory services, the catheter 
placement procedure, the biopsies, an x-ray, the office visits, an ambulance transportation, the surgery services, 
and an inpatient hospital stay provided from January 3, 2022, to September 29, 2022. 
 
You asked the Plan to waive the copayments for the services. You say that you had met your maximum out of 
pocket amount prior to these services. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
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 $5 
copayment for each covered lab service performed in a physician's office. Your contract with the Plan also 
clearly says that you must pay a $10 copayment for each covered lab service performed in an outpatient facility 
department. Your contract with the Plan also clearly says that you must pay a $65 copayment for each covered 
diagnostic procedure or test at a network doctor's office. Your contract with the Plan also clearly says that you 
must pay a $110 copayment for each covered x-ray in the outpatient department of a network hospital or 
facility. Your contract with the Plan also clearly says that you must pay a $5 copayment for each covered 
primary care provider office visit. Your contract with the Plan also clearly says that you must pay a $35 
copayment for each covered specialist office visit. Your contract with the Plan also clearly says that you must 
pay a $260 copayment for each covered, one-way ambulance trip by ground or water. Your contract with the 
Plan also clearly says that you must pay a $285 copayment for each covered surgery or observation room 
service in an outpatient facility. Your contract with the Plan also clearly says that you must pay a $310 
copayment per day, for days 1 to 7 and a $0 copayment per day, for days 8 to 90 of the inpatient hospital stay. 
 
The record shows you had not met your maximum out-of-pocket amount prior to these services. You have been 
asked to pay $5 copayment for the lab services provided on January 31, 2022. You have also been asked to pay 
a $10 copayment for each lab service provided on February 6, 2022, August 17, 2022, August 19, 2022, August 
20, 2022, August 24, 2022, August 29, 2022, September 2, 2022, September 6, 2022, and September 12, 2022. 
You have also been asked to pay a $65 copayment for a catheter placement procedure provided on July 30, 
2022. You have also been asked to pay $14.48, which is less than the standard copayment for the device 
evaluation provided on March 8, 2022. You have also been asked to pay a $65 copayment for each biopsy 
procedure provided on August 22, September 8, 2022, and September 23, 2022. You have also been asked to 
pay $78.41, which is less than the standard copayment for the x-ray provided on September 1, 2022. These 
items/services fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. 
You have also been asked to pay a $5 copayment for each office visit provided on May 12, 2022, May 13, 
2022, August 18, 2022, August 24, 2022, September 1, 2022, September 13, 2022, September 15, 2022, 
September 21, 2022, and September 29, 2022. You have also been asked to pay a $35 copayment for each 
specialist office visit provided on January 3, 2022, February 5, 2022, February 6, 2022, and April 25, 2022. These items/services fall within the physician/practitioner services, including doctor's office visits benefit 
category. You have also been asked to pay a $260 copayment for the ambulance services provided on February 
4, 2022. This item/service falls within the ambulance services benefit category. You have also been asked to 
pay a $285 copayment for each cardiac catheterization procedure provided on May 6, 2022, August 22, 2022, 
September 8, 2022, and September 23, 2022. These items/services fall within the outpatient surgery, including 
services provided at hospital outpatient facilities benefit category. You have also been asked to pay a $310 
copayment per day, for days 1 to 7 of the inpatient hospital stay provided from May 17, 2022, to August 16, 
2022. You have been asked to pay a total of $2,170 ($310 copayment x 7 days = $2,170). This item/service 
falls within the inpatient hospital care benefit category.  The total you have been asked to pay is $4,200 for 
these services. 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 the laboratory services, the catheter 
placement procedure, the biopsies, an x-ray, the office visits, an ambulance transportation, the surgery services, 
and an inpatient hospital stay provided from January 3, 2022, to September 29, 2022.