Negotiated Arrangements. Instead of using the BlueCard Program, BCBSRI may process your Enrolled Member claims for covered healthcare services through Negotiated Arrangements. If BCBSRI and GROUP have agreed that Host Blues shall make available custom healthcare provider networks in connection with this Agreement, then the terms and conditions set forth in BCBSRI Negotiated Arrangements for National Accounts with such Host Blues shall apply. Enrolled Member liability calculation will be based on the negotiated price (refer to the description of negotiated price under Section 7.4.1, BlueCard Program) that the Host Blue makes available to BCBSRI that allows GROUP Enrolled Members access to negotiated participation agreement networks of specified participating healthcare providers outside of BCBSRI service area. Where GROUP agrees to use reference-based benefits, which are service-specific benefit dollar limits for specific procedures, based on a Host Blue’s local market rates, Enrolled Members will be responsible for the amount that the healthcare provider bills above the specific reference benefit limit for a given procedure. For a participating provider, that amount will be the difference between the negotiated price and the reference benefit limit. For a nonparticipating provider, that amount will be the difference between the provider’s billed charge and the reference benefit limit. Where a reference benefit limit exceeds either a negotiated price or a provider’s billed charge, the Enrolled Member will incur no additional liability, other than any applicable Enrolled Member cost sharing.
Negotiated Arrangements. With respect to one or more Host Plans, instead of using the BlueCard Program, Claim Administrator may process Employer’s Covered Persons’ Claims for Covered Services through a Negotiated Arrangement. Pursuant to such a Negotiated Arrangements, the Host Blue(s) has/have agreed to provide, on Claim Administrator’s behalf, Claim Payments and certain administrative services for those Covered Persons of Employer receiving Covered Services in the state and/or service area of the Host Blue(s). Pursuant to the agreement between Claim Administrator and the Host Blue(s), Claim Administrator has agreed to reimburse each Host Blue for all Claim Payments made on Claim Administrator’s behalf for those Covered Persons of Employer receiving Covered Services in the state and/or service area of such Host Blue. In addition, if Claim Administrator and Employer have agreed that (a) Host Blue(s) shall make available (a) custom health care Provider Network(s) in connection with this Agreement, then the terms and conditions set forth in Claim Administrator’s Negotiated Arrangement(s) for national accounts with such Host Blue(s) shall apply. These include the provisions governing the processing and payment of claims when Covered Persons access such networks. In negotiating such arrangement(s), Claim Administrator is not acting on behalf of or as an agent for Employer, Employer’s Plan or Employer’s Covered Persons.
Negotiated Arrangements. Instead of using the BlueCard Program, Blue Cross and Blue Shield of Alabama may process your member claims for covered healthcare services through Negotiated Arrangements. If Blue Cross and Blue Shield of Alabama and Employer have agreed that (a) Host Blue(s) shall make available (a) custom healthcare provider network(s) in connection with this agreement, then the terms and conditions set forth in our Negotiated Arrangement(s) for National Accounts with such Host Blue(s) shall apply. Member liability calculation will be based on the lower of either billed covered charges or negotiated price (refer to the description of negotiated price under Section A, BlueCard Program) that the Host Blue makes available to Blue Cross and Blue Shield of Alabama that allows your members access to negotiated participation agreement networks of specified participating healthcare providers outside of our service area.
Negotiated Arrangements. If we have entered into a Negotiated Arrangement with a Host Blue to provide Value-Based Programs to your members, we will follow the same procedures for Value-Based Programs as noted above for the BlueCard Program.
Negotiated Arrangements. As an alternative to the BlueCard Program, claims for Covered Services may be processed through a negotiated account arrangement with one or more Host Blues. If Anthem has arranged with one or more Host Blues to provide customized networks or other negotiated arrangements, then the terms of any such arrangement will determine the payment amount. A Member’s cost share will be calculated based on the lower of either (i) the billed amount; or (ii) the price that Anthem has negotiated with the Host Blue under the negotiated account arrangement.
Negotiated Arrangements. If Anthem has entered into a Negotiated Arrangement with a Host Blue to provide Value-Based Programs to Members, Anthem will follow the same procedures for Value-Based Programs as noted above for the BlueCard Program.
Negotiated Arrangements. If BCBSNE has entered into a Negotiated Arrangement with a Host Blue to provide Value-Based Programs to employees, BCBSNE will follow the same procedures for Value-Based Programs as noted above for the BlueCard Program. Return of Overpayments Recoveries of overpayments from a Host Blue or its participating and nonparticipating providers can arise in several ways, including, but not limited to, anti-fraud and abuse recoveries, healthcare provider/hospital audits, credit balance audits, utilization review refunds and unsolicited refunds. Recovery amounts determined in the ways noted above will be applied so that corrections will be made, in general, on either a claim-by-claim or prospective basis. If recovery amounts are passed on a claim-by-claim basis from a host Blue to Us, they will be credited to Your account. In some cases, the Host Blue will engage a third party to assist in identification or collection of recovery amounts. The fees of such a third party may be charged to You as a percentage of the recovery. Inter-Plan Programs: Federal/State Taxes/Surcharges/Fees In some instances federal or state laws or regulations may impose a surcharge, tax or other fee that applies to insured accounts. If applicable, BCBSNE will include any such surcharge, tax or other fee in determining Your premium.
