Secondary Plan. The Plan that typically determines its benefits after those of another Plan and may reduce the benefits it pays so that all Plan benefits do not exceed 100% of the total Allowable Expense deemed customary and reasonable by Keystone. Covered Service: A service or supply specified in This Coverage for which benefits will be provided when rendered by a Provider to the extent that such item is not covered completely under the Other Plan. When benefits are provided in the form of services, the reasonable cash value of each service shall be deemed the benefit. Keystone will not be required to determine the existence of any Other Plan, or amount of benefits payable under any Other Plan, except This Coverage. The payment of benefits under This Coverage shall be affected by the benefits that would be payable under Other Plans only to the extent that Keystone is furnished with information regarding Other Plans by the Member or Subscriber or any other organization or person. Allowable Expense: Allowable expense is a health care expense, including Deductibles, Coinsurance, and Copayments, that is covered at least in part by any Plan covering the Member. When a Plan provides benefits in the form of services, the reasonable cash value of each service will be considered an Allowable Expense and a benefit paid. An expense that is not covered by any Plan covering the Member is not an Allowable Expense. In addition, any expense that a Provider by law or in accordance with a contractual agreement is prohibited from charging a Member is not an Allowable Expense. Examples of expenses that are not Allowable Expenses include, but are not limited to: The difference between the cost of a semi-private Hospital room and a private Hospital room, unless one of the Plans provides coverage for private Hospital room expenses. Any amount in excess of the highest reimbursement amount for a specific benefit when two (2) or more Plans that calculate benefit payments on the basis of usual and customary fees or relative value schedule reimbursement methodology or other similar reimbursement methodology cover the Member. Any amount in excess of the highest of the negotiated fees when two (2) or more Plans that provide benefits or services on the basis of negotiated fees cover the Member. If the Member is covered by one Plan that calculates its benefits or services on the basis of usual and customary fees or relative value schedule reimbursement methodology or other similar reimbursement methodology covers a person and another Plan that provides its benefits or services on the basis of negotiated fees, the Primary Plan’s payment arrangement shall be the Allowable Expense for all Plans. However, if the Provider has contracted with the Secondary Plan to provide the benefit or service for a specific negotiated fee or payment amount that is different than the Primary Plan’s payment arrangement and if the Provider’s contract permits, the negotiated fee or payment shall be the Allowable Expense used by the Secondary Plan to determine its benefits. The amount of any benefits reduction by the Primary Plan because the Member has failed to comply with the Plan provisions. Examples of these types of Plan provisions include second surgical opinions, Preauthorization, and preferred provider arrangements. Closed Panel: Closed panel plan is a Plan that provides health care benefits to covered persons primarily in the form of services through a panel of Providers that have contracted with or are employed by the Plan, and that excludes coverage for services provided by other Providers, except in cases of emergency or referral by a panel Member. An HMO is an example of a closed panel plan. Custodial Parent: Custodial parent is the parent awarded custody by a court decree or, in the absence of a court decree, is the parent with whom the child resides more than one half of the calendar year excluding any temporary visitation. Dependent: A dependent means, for any Other Plan, any person who qualifies as a dependent under that plan.
Appears in 5 contracts
Samples: Subscriber Agreement, Subscriber Agreement, Subscriber Agreement
Secondary Plan. The Plan that typically determines its benefits after those of another Plan and may reduce the benefits it pays so that all Plan benefits do not exceed 100% of the total Allowable Expense deemed customary and reasonable by Keystone. Covered Service: A service or supply specified in This Coverage for which benefits will be provided when rendered by a Provider to the extent that such item is not covered completely under the Other Plan. When benefits are provided in the form of services, the reasonable cash value of each service shall be deemed the benefit. Keystone will not be required to determine the existence of any Other Plan, or amount of benefits payable under any Other Plan, except This Coverage. The payment of benefits under This Coverage shall be affected by the benefits that would be payable under Other Plans only to the extent that Keystone is furnished with information regarding Other Plans by the Member or Subscriber or any other organization or person. Allowable Expense: Allowable expense is a health care expense, including Deductibles, Coinsurance, and Copayments, that is covered at least in part by any Plan covering the Member. When a Plan provides benefits in the form of services, the reasonable cash value of each service will be considered an Allowable Expense and a benefit paid. An expense that is not covered by any Plan covering the Member is not an Allowable Expense. In addition, any expense that a Provider by law or in accordance with a contractual agreement is prohibited from charging a Member is not an Allowable Expense. Examples of expenses that are not Allowable Expenses include, but are not limited to: • The difference between the cost of a semi-private Hospital room and a private Hospital room, unless one of the Plans provides coverage for private Hospital room expenses. • Any amount in excess of the highest reimbursement amount for a specific benefit when two (2) or more Plans that calculate benefit payments on the basis of usual and customary fees or relative value schedule reimbursement methodology or other similar reimbursement methodology cover the Member. • Any amount in excess of the highest of the negotiated fees when two (2) or more Plans that provide benefits or services on the basis of negotiated fees cover the Member. • If the Member is covered by one Plan that calculates its benefits or services on the basis of usual and customary fees or relative value schedule reimbursement methodology or other similar reimbursement methodology covers a person and another Plan that provides its benefits or services on the basis of negotiated fees, the Primary Plan’s payment arrangement shall be the Allowable Expense for all Plans. However, if the Provider has contracted with the Secondary Plan to provide the benefit or service for a specific negotiated fee or payment amount that is different than the Primary Plan’s payment arrangement and if the Provider’s contract permits, the negotiated fee or payment shall be the Allowable Expense used by the Secondary Plan to determine its benefits. • The amount of any benefits reduction by the Primary Plan because the Member has failed to comply with the Plan provisions. Examples of these types of Plan provisions include second surgical opinions, Preauthorization, and preferred provider arrangements. Closed Panel: Closed panel plan is a Plan that provides health care benefits to covered persons primarily in the form of services through a panel of Providers that have contracted with or are employed by the Plan, and that excludes coverage for services provided by other Providers, except in cases of emergency or referral by a panel Member. An HMO is an example of a closed panel plan. Custodial Parent: Custodial parent is the parent awarded custody by a court decree or, in the absence of a court decree, is the parent with whom the child resides more than one half of the calendar year excluding any temporary visitation. Dependent: A dependent means, for any Other Plan, any person who qualifies as a dependent under that plan.
Appears in 4 contracts
Samples: Subscriber Agreement, Subscriber Agreement, Subscriber Agreement
Secondary Plan. The Plan that typically determines its benefits after those of another Plan and may reduce the benefits it pays so that all Plan benefits do not exceed 100% of the total Allowable Expense deemed customary and reasonable by Keystone. Covered Service: A service or supply specified in This Coverage for which benefits will be provided when rendered by a Provider to the extent that such item is not covered completely under the Other Plan. When benefits are provided in the form of services, the reasonable cash value of each service shall be deemed the benefit. Keystone will not be required to determine the existence of any Other Plan, or amount of benefits payable under any Other Plan, except This Coverage. The payment of benefits under This Coverage shall be affected by the benefits that would be payable under Other Plans only to the extent that Keystone is furnished with information regarding Other Plans by the Member or Subscriber or any other organization or person. Allowable Expense: Allowable expense is a health care expense, including Deductibles, Coinsurance, and Copayments, that is covered at least in part by any Plan covering the Member. When a Plan provides benefits in the form of services, the reasonable cash value of each service will be considered an Allowable Expense and a benefit paid. An expense that is not covered by any Plan covering the Member is not an Allowable Expense. In addition, any expense that a Provider by law or in accordance with a contractual agreement is prohibited from charging a Member is not an Allowable Expense. Examples of expenses that are not Allowable Expenses include, but are not limited to: The difference between the cost of a semi-private Hospital room and a private Hospital room, unless one of the Plans provides coverage for private Hospital room expenses. Any amount in excess of the highest reimbursement amount for a specific benefit when two (2) or more Plans that calculate benefit payments on the basis of usual and customary fees or relative value schedule reimbursement methodology or other similar reimbursement methodology cover the Member. Any amount in excess of the highest of the negotiated fees when two (2) or more Plans that provide benefits or services on the basis of negotiated fees cover the Member. If the Member is covered by one Plan that calculates its benefits or services on the basis of usual and customary fees or relative value schedule reimbursement methodology or other similar reimbursement methodology covers a person and another Plan that provides its benefits or services on the basis of negotiated fees, the Primary Plan’s payment arrangement shall be the Allowable Expense for all Plans. However, if the Provider has contracted with the Secondary Plan to provide the benefit or service for a specific negotiated fee or payment amount that is different than the Primary Plan’s payment arrangement and if the Provider’s contract permits, the negotiated fee or payment shall be the Allowable Expense used by the Secondary Plan to determine its benefits. The amount of any benefits reduction by the Primary Plan because the Member has failed to comply with the Plan provisions. Examples of these types of Plan provisions include second surgical opinions, Preauthorization, and preferred provider arrangements. Closed Panel: Closed panel plan is a Plan that provides health care benefits to covered persons primarily in the form of services through a panel of Providers that have contracted with or are employed by the Plan, and that excludes coverage for services provided by other Providers, except in cases of emergency or referral by a panel Member. An HMO is an example of a closed panel plan. Custodial Parent: Custodial parent is the parent awarded custody by a court decree or, in the absence of a court decree, is the parent with whom the child resides more than one half of the calendar year excluding any temporary visitation. Dependent: A dependent means, for any Other Plan, any person who qualifies as a dependent under that plan.. Order of Benefit Determination Rules When a Member is covered by two (2) or more Plans, the rules for determining the order of benefit payments are as follows:
Appears in 1 contract
Samples: Subscriber Agreement
Secondary Plan. The Plan that typically determines its benefits after those of another Plan and may reduce the benefits it pays so that all Plan benefits do not exceed 100% of the total Allowable Expense deemed customary and reasonable by Keystone. Covered Service: A service or supply specified in This Coverage for which benefits will be provided when rendered by a Provider to the extent that such item is not covered completely under the Other Plan. When benefits are provided in the form of services, the reasonable cash value of each service shall be deemed the benefit. Keystone will not be required to determine the existence of any Other Plan, or amount of benefits payable under any Other Plan, except This Coverage. The payment of benefits under This Coverage shall be affected by the benefits that would be payable under Other Plans only to the extent that Keystone is furnished with information regarding Other Plans by the Member or Subscriber or any other organization or person. Allowable Expense: Allowable expense is a health care expense, including Deductibles, Coinsurance, and Copayments, that is covered at least in part by any Plan covering the Member. When a Plan provides benefits in the form of services, the reasonable cash value of each service will be considered an Allowable Expense and a benefit paid. An expense that is not covered by any Plan covering the Member is not an Allowable Expense. In addition, any expense that a Provider by law or in accordance with a contractual agreement is prohibited from charging a Member is not an Allowable Expense. Examples of expenses that are not Allowable Expenses include, but are not limited to: The difference between the cost of a semi-private Hospital room and a private Hospital room, unless one of the Plans provides coverage for private Hospital room expenses. Any amount in excess of the highest reimbursement amount for a specific benefit when two (2) or more Plans that calculate benefit payments on the basis of usual and customary fees or relative value schedule reimbursement methodology or other similar reimbursement methodology cover the Member. Any amount in excess of the highest of the negotiated fees when two (2) or more Plans that provide benefits or services on the basis of negotiated fees cover the Member. If the Member is covered by one Plan that calculates its benefits or services on the basis of usual and customary fees or relative value schedule reimbursement methodology or other similar reimbursement methodology covers a person and another Plan that provides its benefits or services on the basis of negotiated fees, the Primary Plan’s payment arrangement shall be the Allowable Expense for all Plans. However, if the Provider has contracted with the Secondary Plan to provide the benefit or service for a specific negotiated fee or payment amount that is different than the Primary Plan’s payment arrangement and if the Provider’s contract permits, the negotiated fee or payment shall be the Allowable Expense used by the Secondary Plan to determine its benefits. benefits. The amount of any benefits reduction by the Primary Plan because the Member has failed to comply with the Plan provisions. Examples of these types of Plan provisions include second surgical opinions, Preauthorization, and preferred provider arrangements. Closed Panel: Closed panel plan is a Plan that provides health care benefits to covered persons primarily in the form of services through a panel of Providers that have contracted with or are employed by the Plan, and that excludes coverage for services provided by other Providers, except in cases of emergency or referral by a panel Member. An HMO is an example of a closed panel plan. Custodial Parent: Custodial parent is the parent awarded custody by a court decree or, in the absence of a court decree, is the parent with whom the child resides more than one half of the calendar year excluding any temporary visitation. Dependent: A dependent means, for any Other Plan, any person who qualifies as a dependent under that plan.
Appears in 1 contract
Samples: Subscriber Agreement
