Recognized Charge definition

Recognized Charge means the negotiated charge contained in an agreement the claims administrator has with the provider either directly or through a third party. If there is no such agreement, the Recognized Charge is determined in accordance with the provisions of this section.

Recognized Charge means the negotiated charge contained in an agreement the claims administrator has with the provider either directly or through a third party. If there is no such agreement, the recognized charge is determined in accordance with the provisions of this section. An out-of-network provider has the right to bill the difference between the recognized charge and the actual charge. This difference will be the covered person's responsibility.

Recognized Charge is defined in GovGuam’s Pharmacy Plan. Where a similar term (such as “reasonable charge amount”) is used in GovGuam’s Plan instead of “recognized charge”, it will have the same meaning as Recognized Charge.

Examples of Recognized Charge in a sentence

• The Recognized Charge section now appearing in the How Your Plan Works section in your booklet is revised as follows.

• If there is no such agreement, the prescription drug expense Recognized Charge for each service or supply is the lesser of:a) What the provider bills or submits for that service or supply;b) 110% of the average wholesale price or other similar resource; orc) For Medicare eligible retirees and dependents covered under the Medicare prescription drug plan, the Medicare Part D approved amount.

• Primary Plan is Fee Schedule Plan and Secondary Plan is Recognized Charge Plan or Fee Schedule PlanIf the Primary Plan is an HMO plan that does not allow for the use of non-network providers except in the event of urgent care or emergency care and the service or supply the Covered Person receives from a non-network provider is not considered as urgent care or emergency care, the Secondary Plan shall pay benefits as if it were the Primary Plan.

• The Recognized Charge is based on the provider’s estimated cost, including an anticipated profit margin.

• In no event shall the covered person be responsible for any payment in excess of the deductible, coinsurance or copayment of the Secondary Plan.Primary Plan is Fee Schedule Plan and Secondary Plan is Recognized Charge PlanIf the provider is a Network Provider in the Primary Plan, the Allowable Expense considered by the Secondary Plan shall be the fee schedule of the Primary Plan.

• For the Legacy Dental Plan coinsurance is calculated using the recognized charge as outlined in section 9.1.4, Recognized Charge.

• Recognized Charge (RC) is a charge which is not higher than the usual charge made by the provider of the care or supply and does not exceed the usual charge made by most providers of like service in the same area.

• The Plan will reimburse the actual charge billed if it is less than the Recognized Charge.

• Benefits for medically necessary and appropriate authorized referral services received from a non-network provider will be payable as shown in the SCHEDULES FOR NON-NETWORK PROVIDERS (benefits will be reimbursed based on Recognized Charge).

• Fixed Determination FCRIn the event that a member is balance billed or the facility appeals, the member is responsible for charges in excess of the Recognized Charge for voluntary out-of-network claims.