Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that a Medicare plan may restrict members to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the Plan must 
arrange for specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(3). 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The health 
plan contract says, "Our plan will cover services from either network or out-of-network providers, as long as 
the services are covered benefits and are medically necessary. However, if you use an out-of-network provider, 
your share of the costs for your covered services may be higher. Here are other important things to know about 
using out-of-network providers: 
You can get your care from an out-of-network provider; however, in most cases that provider must be eligible 
to participate in Medicare. Except for emergency care, we cannot pay a provider who is not eligible to 
participate in Medicare. If you receive care from a provider who is not eligible to participate in Medicare, you 
will be responsible for the full cost of the services you receive. Check with your provider before receiving 
services to confirm that they are eligible to participate in Medicare. 
If a provider is not available in the network within a reasonable distance from your home, you can ask us to see 
an out-of-network provider (called a coverage decision). If the request is approved, you will pay the 
applicable in-network cost sharing and the provider will be reimbursed at the in-network allowable charge. To 
ask for a coverage decision, please refer to Section 4.1 of Chapter 9, Asking for coverage decisions and making 
appeals: the big picture. 
You dont need to get a referral or prior authorization when you get care from out-of-network providers. 
However, before getting services from out-of-network providers you may want to ask for a pre-visit coverage 
decision (see definition in Chapter 12) to confirm that the services you are getting are covered and are medically necessary. (See Chapter 9, Section 4 for information about asking for coverage decisions.) This is 
important because: 
Without a pre-visit coverage decision, if we later determine that the services are not covered or were not 
medically necessary, we may deny coverage and you will be responsible for the entire cost. If we say we will 
not cover your services, you have the right to appeal our decision not to cover your care. See Chapter 9 (What 
to do if you have a problem or complaint) to learn how to make an appeal. 
It is best to ask an out-of-network provider to bill the plan first. But, if you have already paid for the covered 
services, we will reimburse you for our share of the cost for covered services. Or if an out-of-network provider 
sends you a bill that you think we should pay, you can send it to us for payment. See Chapter 7 (Asking us to 
pay our share of a bill you have received for covered medical services or drugs) for information about what to 
do if you receive a bill or if you need to ask for reimbursement.  
If you are using an out-of-network provider for emergency care, urgently needed services, or out-of-area 
dialysis, you may not have to pay a higher cost sharing amount. See Section 3 for more information about these 
situations." You can find this information in Chapter 4 on pages 51-52 of the plan's 2022 Evidence of 
Coverage.