PROVIDER NETWORK STATUS. The allowed amount may vary depending upon whether the Provider is an In-Network or an Out-of-Network Provider. For Covered Services performed by an In-Network Provider, the allowed amount for this plan is the rate the Provider has agreed with Alliant to accept as reimbursement for the Covered Services. Because In-Network Providers have agreed to accept the allowed amount as payment in full for that service, they should not send you a bill or collect for amounts above the allowed amount. However, you may receive a bill or be asked to pay all or a portion of the allowed amount to the extent you have not met your Deductible or have a copayment or Coinsurance. Please call customer service at (000) 000-0000 for help in finding an In-Network Provider or visit XxxxxxxXxxxx.xxx. Providers who have not signed a contract with us and are not in any of our networks are Out-of-Network Providers. For Covered Services you receive from Out-of-Network Providers (other than emergency services), the MAC for this plan will be one of the following as determined by Alliant: • An amount based on our out-of-network fee schedule/rate, which we have established at our discretion, and which we reserve the right to modify from time to time, after considering one or more of the following: reimbursement amounts accepted by like/similar providers contracted with Alliant, reimbursement amounts paid by the Centers for Medicare and Medicaid Services for the same services or supplies, and other industry cost, reimbursement and utilization data; or • An amount based on information provided by a third-party vendor, which may reflect one or more of the following factors: (1) the complexity or severity of treatment; (2) level of skill and experience required for the treatment; or (3) comparable providers’ fees and costs to deliver care; or • An amount negotiated by us or a third- party vendor which has been agreed to by the Provider. This may include rates for services coordinated through case management; or • An amount equal to the total charges billed by the Provider, but only if such charges are less than the MAC calculated by using one of the methods described above. The MAC for out-of-network Emergency Medical Services is calculated as described in the Department of Labor Regulation 29 CFR 2590.715-2719A(b)(3)(i)(A), (B) & (C); with respect to emergency services we will calculate the MAC as: • The amount negotiated with In-Network Providers for the emergency service furnished, excluding a...
PROVIDER NETWORK STATUS. The Maximum Allowed Amount may vary depending upon whether the provider is a Prudent Buyer Plan Provider, a Non-Prudent Buyer Plan Provider or a Related Health Provider. Prudent Buyer Plan Providers and CME. For covered services performed by a Prudent Buyer Plan Provider or CME the Maximum Allowed Amount for this Plan will be the rate the Prudent Buyer Plan Provider or CME has agreed with us to accept as reimbursement for the covered services. Because Prudent Buyer Plan Providers have agreed to accept the Maximum Allowed Amount as payment in full for those covered services, they should not send you a bill or collect for amounts above the Maximum Allowed Amount. However, you may receive a bill or be asked to pay all or a portion of the Maximum Allowed Amount to the extent you have not met your Deductible or have a Co-Payment. Please call the customer service telephone number on your ID card for help in finding a Prudent Buyer Plan Provider or visit xxx.xxxxxx.xxx/xx. If you go to a Hospital which is a Prudent Buyer Plan Provider, you should not assume all providers in that Hospital are also Prudent Buyer Plan Providers. To receive the greater benefits afforded when covered services are provided by a Prudent Buyer Plan Provider, you should request that all your provider services (such as services by an anesthesiologist) be performed by Prudent Buyer Plan Providers whenever you enter a Hospital. If you are planning to have outpatient surgery, you should first find out if the facility where the surgery is to be performed is an Ambulatory Surgical Center. An Ambulatory Surgical Center is licensed as a separate facility even though it may be located on the same grounds as a Hospital (although this is not always the case). If the center is licensed separately, you should find out if the facility is a Prudent Buyer Plan Provider before undergoing the surgery.
