Eligible Charge. For a medical service or supply that qualifies for payment under Title XVIII of the Social Security Act (“Title XVIII”) and the regulations and subregulatory guidance promulgated thereunder by CMS (the “Medicare Rules”), the Eligible Charge for a Covered Service is the lower of (a) the actual charge as shown on the Claim or (b) the amount that otherwise would have been paid directly to the Provider under Title XVIII and Medicare Rules for the service or supply (the “Medicare Payment Amount”). Where a Medicare Payment Amount has not been established, the Eligible Charge shall be the lower of (a) the actual charge as shown on the Claim or (b) the charge listed in HMSA's Schedule of Maximum Allowable Charges (the “Schedule”). HMSA reserves the right to adjust the charges listed in the Schedule upon sixty (60) days’ written notice to Provider. Factors considered by HMSA in making these adjustments may include, but are not limited to, changes in the Honolulu Consumer Price Indices (All Items and Medical Care); cost of providing medical care; relative complexity of the service; payments for the service under federal, state, and other private insurance programs; and the competitive environment. For a Covered Service that does not have a charge listed in the Schedule, HMSA will establish the Maximum Allowable Charge.
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Sources: Allied Health Provider Agreement for Medicare Plans, Allied Health Provider Agreement for Medicare Plans