Eligible Charge definition
Eligible Charge means any necessary, reasonable, and customary item of which at least a portion is covered under this Plan, but does not include:
Eligible Charge means the treating health care provider's usual, customary and reasonable charge or the upper limit of the medical fee schedule as found in N.J.A.C. 11:3-29.6, whichever is lower.
Eligible Charge means (a) in the case of a Provider, other than a Professional Provider, which has a written agreement with Blue Cross and Blue Shield of Illinois or another Blue Cross and/or Blue Shield Plan to provide care to participants in the benefit program, or is designated as a Participating Provider by any Blue Cross and/or Blue Shield Plan, at the time Covered Services are rendered, such Provider’s Claim Charge for Covered Services and (b) in the case of a Provider, other than a Professional Provider, which does not have a written agreement with Blue Cross and Blue Shield of Illinois or another Blue Cross and/or Blue Shield Plan to provide care to participants in the benefit program, or is not designated as a Participating Provider by any Blue Cross and/or Blue Shield Plan, at the time Covered Services are rendered, the following amount (unless otherwise required by applicable law or arrangement with the Non- Participating Provider):
Examples of Eligible Charge in a sentence
Prime will also process and pay Paper Claims received from a Member at the benefit level set forth in the Benefit Plan, and based on the Prescription Drug Program Eligible Charge, in accordance with the terms of the Benefit Plan, provided that the Benefit Plan allows such reimbursement.
Prime will implement the methodology described in the Prescription Drug Program Eligible Charge when calculating the Copayment/Deductible, and Coinsurance amounts.
More Definitions of Eligible Charge
Eligible Charge means (a) in the case of a Provider which has a written agreement with the Plan or the entity chosen by the Plan to administer its prescription drug program to provide Covered Services to you at the time you receive the Covered Services, such Provider's Claim Charge for Covered Services and (b) in the case of a Provider which does not have a written agreement with the Plan or the entity chosen by the Plan to provide services to you at the time you receive Covered Services, either of the following charges for Covered Services:
Eligible Charge means (a) in the case of a Provider which has a written agreement with a Blue Cross and Blue Shield Plan or the entity chosen by Blue Cross and Blue Shield to administer its prescription drug program to provide Covered Services to you at the time you receive the Covered Services, such Provider’s Claim Charge for Cov- ered Services and (b) in the case of a Provider which does not have a written agreement with a Blue Cross and Blue Shield Plan or the entity chosen by Blue Cross and Blue Shield to provide services to you at the time you receive Covered Services, either of the following charges for Covered Services:
Eligible Charge means any charge against a person on or after January 1, 2027, if the records relating to the charge are eligible to be sealed pursuant to subsection 1 of NRS 179.255 for a drug-related charge, including, without limitation, a charge pursuant to paragraph (c) or (g) of subsection 1 of NRS 179.245, for a drug- related conviction charge ,including, without limitation, a conviction charge pursuant to paragraph (a) of subsection 2 of NRS 453.336, subsection 4 or 5 of NRS 453.336, subsection 2 of NRS 453.3393 or NRS 453.560 or 454.351.
Eligible Charge means the charge determined by the Trust Fund according to the criteria in Section 3.7 and is the charge used to calculate the benefit payment for a covered service.
Eligible Charge means the lower of Provider’s billed charge or the agreed upon amount for reimbursement that Provider shall receive for Covered Services to Eligible Persons. UHA’s actual payment to Provider shall be less the Eligible Person’s Copayment.
Eligible Charge means (a) in the case of a Provider, other than a professional Provider, which has a written agreement with Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide care to Covered Persons, or is designated as a Participating Provider by any Blue Cross and/or Blue Shield Plan, at the time Covered Services for medical benefits are rendered (“Participating Provider”), such Participating Provider’s Claim Charge for Covered Services; and (b) in the case of a Provider, other than a professional Provider, which does not have a written agreement with Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide care to Covered Persons, or is not designated as a Participating Provider by any Blue Cross and/or Blue Shield Plan, at the time Covered Services for medical benefits are rendered (“Non-Participating Provider”), the following amount (unless otherwise required by applicable law or arrangement with the Non-Participating Provider):
i. the lesser of (A) the Provider’s standard Claim Charges, and (B) an amount determined by Claim Administrator to be approximately one hundred percent (100%) of the base Medicare reimbursement rate, excluding any Medicare adjustment(s) which is/are based on information on the Claim; or
ii. if there is no base Medicare reimbursement rate available for a particular Covered Service, or if the base Medicare reimbursement amount cannot otherwise be determined under subsection (i) above based upon the information submitted on the Claim, the lesser of (A) the Provider’s standard Claim Charges and (B) an amount determined by Claim Administrator to be one hundred fifty percent (150%) of the Maximum Allowance that would apply if the services were rendered by a Participating Professional Provider on the date of service; or
iii. if the base Medicare reimbursement amount and the Eligible Charge cannot be determined under subsections (i) or (ii) above, based upon the information submitted on the Claim, then the amount will be fifty percent (50%) of the Provider’s standard Claim Charges, provided, however, that Claim Administrator may limit such amount to the lowest contracted rate that Claim Administrator has with a Participating Provider for the same or similar service based upon the type of provider and the
Eligible Charge means (a) in the case of a Provider, other than a professional Provider, which has a written agreement with Claim Administrator or another Blue Cross and Blue Shield Plan to provide care to Covered Persons, or is designated as a participating Provider by any Blue Cross and Blue Shield Plan, at the time Covered Services for medical benefits are rendered (“Participating Provider”), such Participating Provider’s Claim Charge for Covered Services; and (b) in the case of a Provider, other than a professional Provider, which does not have a written agreement with Claim Administrator or another Blue Cross and Blue Shield Plan to provide care to Covered Persons, or is not designated as a Participating Provider by any Blue Cross and Blue Shield Plan, at the time Covered Services for medical benefits are rendered (“Non- Participating Provider”), the following amount (unless otherwise required by applicable law or arrangement with the Non-Participating Provider):