Coverage for Services Provided Sample Clauses

Coverage for Services Provided. Outside Our Service Area BCBSRI has a variety of relationships with other Blue Cross and/or Blue Shield Licensees. Generally, these relationships are called “Inter-Plan Arrangements.” These Inter-Plan Arrangements work based on rules and procedures issued by the Blue Cross and Blue Shield Association (“Association”). Whenever you access healthcare services outside the geographic area BCBSRI serves, the claim for those services may be processed through one of these Inter-Plan Arrangements, as described below. When you receive care outside of the BCBSRI service area, you will receive it from one of two kinds of providers. Most providers (“participating providers”) contract with the local Blue Cross and/or Blue Shield Plan in that geographic area (“Host Blue”). Some providers (“nonparticipating providers”) don’t contract with the Host Blue. We explain below how we pay both kinds of providers. This plan covers only limited healthcare services received outside of the BlueCHiP Direct service area. As used in this section, “Out-of-Area covered healthcare services” include the following services obtained outside the geographic area we serve: Emergency care (emergency room, urgent care center and ambulance services); services for which we specifically approve the use of a non-network provider; and otherwise, as required by law. Any other services will not be covered when processed through any Inter-Plan Arrangements, including Blue Cross Blue Shield Global® Core, unless authorized by us. All claim types are eligible to be processed through Inter-Plan Arrangements, as described above, except for all dental benefits, and those prescription drug benefits or vision benefits that may be administered by a third party contracted by us to provide the specific service or services. BlueCard® Program Under the BlueCard® Program, when you receive covered healthcare services within the geographic area served by a Host Blue, BCBSRI will remain responsible for doing what we agreed to in the contract. However, the Host Blue is responsible for contracting with and generally handling all interactions with its participating providers. When you receive covered healthcare services outside our service area and the claim is processed through the BlueCard Program, the amount you pay for covered healthcare services is calculated based on the lower of: • the billed covered charges for your covered services; or • the negotiated price that the Host Blue makes available to BCBSRI. The BlueCard...