Common use of Contracted Providers Clause in Contracts

Contracted Providers. In some cases, an out-of-network provider may have a contract with us, but is not part of your network. Even though your bills will be reimbursed at the lower percentage (the out-of-network benefit level), contracted providers will not bill you for the amount above the allowed amount for a covered service.  Non-contracted providers. Out-of-network non-contracted providers do not have a contract with us or with any of the other networks used by this plan. These providers will bill you the amount above the allowed amount for a covered service. In-Network Benefits for Out-of-Network Providers The following covered services and supplies provided by out-of-network providers will always be covered at the in-network level of benefits (based on the out-of-network allowed amount):  Emergency care for a medical emergency. (Please see the "Definitions" section for definitions of these terms.) This plan provides worldwide coverage for emergency care.  The benefits of this plan will be provided for covered emergency care without the need for any prior authorization and without regard as to whether the health care provider furnishing the services is a network provider. Emergency care furnished by an out-of-network provider will be reimbursed on the same basis as a network provider. As explained above, if you see an out-of-network provider, you may be responsible for amounts that exceed the allowed amount.  Services from certain categories of providers to which provider contracts are not offered. These types of providers are generally not listed in the provider directory.  Services associated with admission by an in-network provider to an in-network hospital that are provided by hospital-based providers.  Facility and hospital-based provider services received in Washington from a hospital that has a provider contract with us, if you were admitted to that hospital by an in-network provider who doesn’t have admitting privileges at an in-network hospital.  Covered services received from providers located outside the United States. If a covered service is not available from an in-network provider, you can receive benefits for services provided by an out-of-network provider at the in-network benefit level. However, you must request this before you get the care. See Prior Authorization for details.

Contracted Providers. In some cases, an out-of-network provider may have a contract with us, but is not part of your network. Even though your bills will be reimbursed at the lower percentage (the out-of-network benefit level), contracted providers will not bill you for the amount above the allowed amount for a covered service.  • Non-contracted providers. Out-of-network non-contracted providers do not have a contract with us or with any of the other networks used by this plan. These providers will bill you the amount above the allowed amount for a covered service. In-Network Benefits for Out-of-Network Providers The following covered services and supplies provided by out-of-network providers will always be covered at the in-network level of benefits (based on the out-of-network allowed amount):  • Emergency care for a medical emergency. (Please see the "Definitions" section for definitions of these terms.) This plan provides worldwide coverage for emergency care.  • The benefits of this plan will be provided for covered emergency care without the need for any prior authorization and without regard as to whether the health care provider furnishing the services is a network provider. Emergency care furnished by an out-of-network provider will be reimbursed on the same basis as a network provider. As explained above, if you see an out-of-network provider, you may be responsible for amounts that exceed the allowed amount.  • Services from certain categories of providers to which provider contracts are not offered. These types of providers are generally not listed in the provider directory.  • Services associated with admission by an in-network provider to an in-network hospital that are provided by hospital-based providers.  • Facility and hospital-based provider services received in Washington from a hospital that has a provider contract with us, if you were admitted to that hospital by an in-network provider who doesn’t have admitting privileges at an in-network hospital.  • Covered services received from providers located outside the United States. If a covered service is not available from an in-network provider, you can receive benefits for services provided by an out-of-network provider at the in-network benefit level. However, you must request this before you get the care. See Prior Authorization for details.

Contracted Providers. In some cases, an out-of-of- network provider may have a contract with us, but is not part of your network. Even though your bills will be reimbursed at the lower percentage (the When a service is covered by an out-of-network benefit level)provider, a contracted providers provider will not bill you for the amount above the allowed amount for a covered service.  • Non-contracted providers. Out-of-network non-non- contracted providers do not have a contract with us or with any of the other networks used by this plan. These When a service is covered by an out-of- network provider, these providers will bill you the amount above the allowed amount for a covered service. Providers Outside Washington Benefits of this plan are limited to a medical emergency, see Definitions, when you receive services and supplies in Xxxxx County Washington or outside Washington. Covered services and supplies for medical emergencies can be furnished by any providers that meet the following requirements: • State-licensed or state-certified • Performing services within the scope of their license or certification If, by chance, you get emergency care from a provider that has a provider agreement with us in Alaska or the local Blue Cross and/or Blue Shield Licensee through the BlueCard® Program, your out- of-pocket expenses may be reduced. This is because those providers accept the allowable charge for a covered service as payment in full. When you receive covered emergency care from one of these contracted providers, you’re responsible only for any deductible, copays, or coinsurance required by this plan. In-Network Benefits for Out-of-Network Providers The following covered services and supplies provided by out-of-network providers will always be covered at the in-network level of benefits (based on the out-of-network allowed amount):  • Emergency care for a medical emergency. (Please see the "Definitions" section for definitions of these terms.) This plan provides worldwide coverage for emergency care.  The benefits of this plan will be provided for covered emergency care without the need for any prior authorization and without regard as to whether the health care provider furnishing the services is a network provider. Emergency care furnished by an out-of-network provider will be reimbursed on the same basis as a network provider. As explained above, if you see an out-out- of-network provider, you may be responsible for amounts that exceed the allowed amount.  • Services from certain categories of providers to which provider contracts are not offered. These types of providers are generally not listed in the provider directory.  • Services associated with admission by an in-in- network provider to an in-network hospital that are provided by hospital-based providers.  • Facility and hospital-based provider services received in Washington from a hospital that has a provider contract with us, if you were admitted to that hospital by an in-network provider who doesn’t have admitting privileges at an in-network hospital.  • Covered services received from providers located outside the United States. If a covered service is not available from an in-in- network provider, you can receive benefits for services provided by an out-of-network provider at the in-network benefit level. However, you must request this before you get the care. See Prior Authorization for details.

Contracted Providers. In some cases, an out-of-of- network provider may have a contract with us, but is not part of your network. Even though your bills will be reimbursed at the lower percentage (the When a service is covered by an out-of-network benefit level)provider, a contracted providers provider will not bill you for the amount above the allowed amount for a covered service.  Non-contracted providers. Out-of-network non-non- contracted providers do not have a contract with us or with any of the other networks used by this plan. These When a service is covered by an out-of- network provider, these providers will bill you the amount above the allowed amount for a covered service. Providers Outside Washington Benefits of this plan are limited to a medical emergency, see Definitions, when you receive services and supplies in Xxxxx County Washington or outside Washington. Covered services and supplies for medical emergencies can be furnished by any providers that meet the following requirements:  State-licensed or state-certified  Performing services within the scope of their license or certification If, by chance, you get emergency care from a provider that has a provider agreement with us in Alaska or the local Blue Cross and/or Blue Shield Licensee through the BlueCard® Program, your out- of-pocket expenses may be reduced. This is because those providers accept the allowable charge for a covered service as payment in full. When you receive covered emergency care from one of these contracted providers, you’re responsible only for any deductible, copays, or coinsurance required by this plan. In-Network Benefits for Out-of-Network Providers The following covered services and supplies provided by out-of-network providers will always be covered at the in-network level of benefits (based on the out-of-network allowed amount):  Emergency care for a medical emergency. (Please see the "Definitions" section for definitions of these terms.) This plan provides worldwide coverage for emergency care.  The benefits of this plan will be provided for covered emergency care without the need for any prior authorization and without regard as to whether the health care provider furnishing the services is a network provider. Emergency care furnished by an out-of-network provider will be reimbursed on the same basis as a network provider. As explained above, if you see an out-out- of-network provider, you may be responsible for amounts that exceed the allowed amount.  Services from certain categories of providers to which provider contracts are not offered. These types of providers are generally not listed in the provider directory.  Services associated with admission by an in-in- network provider to an in-network hospital that are provided by hospital-based providers.  Facility and hospital-based provider services received in Washington from a hospital that has a provider contract with us, if you were admitted to that hospital by an in-network provider who doesn’t have admitting privileges at an in-network hospital.  Covered services received from providers located outside the United States. If a covered service is not available from an in-in- network provider, you can receive benefits for services provided by an out-of-network provider at the in-network benefit level. However, you must request this before you get the care. See Prior Authorization for details.