Special Cases: Value-Based Programs. Enrollees may access covered services from providers that participate in a Blue Shield Life Value-Based Program. Blue Shield Life Value-Based Programs include, but are not limited to, Accountable Care Organizations, Episode Based Payments, Patient Centered Medical Homes and Shared Savings arrangements. Blue Shield Life has included any associated costs in the Dues for Blue Shield Life Value-Based Programs when applicable under this agreement.
Special Cases: Value-Based Programs. BlueCard® Program If you receive covered health care services under a Value-Based Program inside a Host Blue’s service area, you will not be responsible for paying any of the Provider Incentives, risk-sharing, and/or Care Coordinator Fees that are a part of such an arrangement, except when a Host Blue passes these fees to us through average pricing or fee schedule adjustments. The following defined terms only apply to Section 5.3: • Care Coordinator Fee is a fixed amount paid by us to providers periodically for Care Coordination under a Value-Based Program. • Care Coordination is organized, information-driven patient care activities intended to facilitate the appropriate responses to an enrolled member's healthcare needs across the continuum of care. • Value-Based Program (VBP) is an outcomes-based payment arrangement and/or a coordinated care model facilitated with one or more local providers that is evaluated against cost and quality metrics/factors and is reflected in provider payment. • Provider Incentive is an additional amount of compensation paid to a healthcare provider by us, based on the provider's compliance with agreed-upon procedural and/or outcome measures for a particular group of covered persons. Inter-Plan Programs: Federal/State Taxes/Surcharges/Fees Federal or state laws or regulations may require a surcharge, tax or other fee that applies to insured accounts. If applicable, we will include any such surcharge, tax or other fee as part of the claim charge passed on to you. Nonparticipating Providers Outside Our Service Area
Special Cases: Value-Based Programs. We have included a factor for bulk distributions from Host Blues in Group’s/Policyholder’s premium for Value-Based Programs when applicable under this Benefit Plan.
Special Cases: Value-Based Programs. BlueCard Program We have included a factor for bulk distributions from Host Blues in your premium for Value-Based Programs when applicable under this agreement.
Special Cases: Value-Based Programs. Blue Shield has included a factor for bulk distributions from Host Blues in the premium for Value-Based Programs when applicable under this agreement. Non-Participating Providers Outside of California When Covered Services, other than Emergency Services, are received from non-participating providers outside of California, but within the BlueCard Service Area, the amount(s) a Member pays for such services will generally be based on the Host Blue’s non-participating provider local payment, the Allowable Amount Blue Shield pays a Non-Participating provider in California if the Host Blue has no non-participating provider allowance, or the pricing arrangements required by applicable state law. In these situations, the Member may be responsible for the difference between the amount that the non-participating provider bills and the payment Blue Shield will make for the Covered Services as set forth in this paragraph. Claims for covered Emergency Services are paid based on the Allowable Amount as defined in the EOC. Blue Shield Global Core If Members are outside the BlueCard Service Area, they may be able to take advantage of Blue Shield Global Core when accessing Out-of-Area Covered Health Care Services. Blue Shield Global Core is unlike the BlueCard Program available in the BlueCard Service Area. Although Blue Shield Global Core assists Members with accessing a network of inpatient, outpatient, and professional providers, the network is not served by a Host Blue plan. As such, when Members receive care from providers outside the BlueCard Service Area, Members will typically have to pay the providers and submit the claims themselves to obtain reimbursement for these services. Details for Blue Shield Global Core claim submission are provided in the Out-of-area services section of the EOC.
Special Cases: Value-Based Programs. BlueCard® Program If you receive covered health care services under a Value-Based Program inside a Host Blue’s service area, you will not be responsible for paying any of the Provider Incentives, risk-sharing, and/or Care Coordinator Fees that are a part of such an arrangement, except when a Host Blue passes these fees to us through average pricing or fee schedule adjustments. The following defined terms only apply to Section 5.3: • Care Coordinator Fee is a fixed amount paid by us to providers periodically for Care Coordination under a Value-Based Program. • Care Coordination is organized, information-driven patient care activities intended to facilitate the appropriate responses to an enrolled member's healthcare needs across the continuum of care. • Value-Based Program (VBP) is an outcomes-based payment arrangement and/or a coordinated care model facilitated with one or more local providers that is evaluated against cost and quality metrics/factors and is reflected in provider payment. • Provider Incentive is an additional amount of compensation paid to a healthcare provider by us, based on the provider's compliance with agreed-upon procedural and/or outcome measures for a particular group of covered persons. Nonparticipating Providers Outside the Network Blue New England Service Area
Special Cases: Value-Based Programs. BlueCard Program Anthem has included a factor for bulk distributions from Host Blues in the premium for Value-Based Programs when applicable under this Contract.
Special Cases: Value-Based Programs. BlueCard® Program If you receive Covered Services under a Value- Based Program inside a Host Blue’s service area, you will not be responsible for paying any of the Provider Incentives, risk-sharing, and/or Care Co- ordinator Fees that are a part of such an arrange- ment, except when a Host Blue passes these fees to Blue Shield through average pricing or fee schedule adjustments. Negotiated (non–BlueCard Program) Arrange- ments If Blue Shield has entered into a Negotiated Ar- rangement with a Host Blue to provide Value- Based Programs to the Employer on your behalf, Blue Shield will follow the same procedures for Value-Based Programs administration and Care Coordinator Fees as noted above for the BlueCard Program. Utilization Management State law requires that Health Plans disclose to Members and Health Plan providers the process used to authorize or deny health care services un- der the Plan. Blue Shield has completed documen- tation of this process as required under Section 1363.5 of the California Health and Safety Code. The document describing Blue Shield’s Utilization Management Program is available online at xxx.xxxxxxxxxxxx.xxx or Members may call the Customer Service Department at the number pro- vided on the back page of this EOC to request a copy.
Special Cases: Value-Based Programs. BlueCard® Program If Members receive Covered Services under a Value-Based Program inside a Host Blue's service area, you will not be responsible for paying any of the provider incentives, risk- sharing, and/or care coordinator fees that are part of such an arrangement, except when a Host Blue passes these fees to the Plan through average pricing or fee schedule adjustments.
Special Cases: Value-Based Programs. Blue Shield Value-Based Programs You may have access to Covered Services from providers that participate in a Blue Shield Value- Based Program. Blue Shield Value-Based Pro- grams include, but are not limited to, Accountable Care Organizations, Episode Based Payments, Pa- tient Centered Medical Homes, and Shared Sav- ings arrangements. If you receive covered services under a Blue Shield Value-Based Program, you will not be re- sponsible for paying any of the Provider Incen- tives, risk-sharing, and/or Care Coordinator Fees that are a part of such an arrangement. BlueCard® Program If you receive Covered Services under a Value- Based Program inside a Host Blue’s service area, you will not be responsible for paying any of the Provider Incentives, risk-sharing, and/or Care Co- ordinator Fees that are a part of such an arrange- ment, except when a Host Blue passes these fees to Blue Shield through average pricing or fee schedule adjustments. Utilization Management State law requires that Health Plans disclose to Members and Health Plan providers the process used to authorize or deny health care services un- der the Plan. Blue Shield has completed documen- tation of this process as required under Section 1363.5 of the California Health and Safety Code. The document describing Blue Shield’s Utilization Management Program is available online at xxx.xxxxxxxxxxxx.xxx or Members may call the Customer Service Department at the number pro- vided on the back page of this EOC to request a copy.
