Liability Calculation Method Per Claim. Unless subject to a fixed dollar copayment, the calculation of Member liability on claims for Out-of-Area Covered Health Care Services processed through the BlueCard Program will be based on the lower of the provider’s billed charges or the negotiated price made available to Blue Shield by the Host Blue. Host Blues determine a negotiated price, which is reflected in the terms of each Host Blue’s health care provider contracts. The negotiated price made available to Blue Shield by the Host Blue may be represented by one of the following:
Liability Calculation Method Per Claim. Unless subject to a fixed dollar copayment, the calculation of the Enrolled Member liability on claims for covered healthcare services will be based on the lower of the participating provider's billed covered charges or the negotiated price made available to BCBSRI by the Host Blue. Host Blues determine a negotiated price, which is reflected in the terms of each Host Blue’s healthcare provider contracts. The negotiated price made available to BCBSRI by the Host Blue may be represented by one of the following:
Liability Calculation Method Per Claim. The calculation of a Member's liability on claims for covered health care services incurred outside the geographic area BCBSM serves and processed through BlueCard will be based on the lower of the provider's billed charges or the negotiated price BCBSM pays the Host Plan. The methods employed by a Host Plan to determine a negotiated price will vary among Host Plans based on the terms of each Host Plan's provider contracts. The negotiated price paid to a Host Plan by BCBSM on a claim for health care services processed through BlueCard may represent:
Liability Calculation Method Per Claim. In General Member Liability Calculation Unless subject to a fixed dollar copayment, the calculation of the member liability on claims for covered healthcare services will be based on the lower of the participating provider's billed covered charges or the negotiated price made available to Florida Blue by the Host Blue. Employer Liability Calculation The calculation of Employer liability on claims for covered healthcare services processed through the BlueCard Program will be based on the negotiated price made available to Florida Blue by the Host Blue (under the contract between the Host Blue and the provider). Sometimes, this negotiated price may be greater for a given service or services than the billed charge in accordance with how the Host Blue has negotiated with its participating healthcare provider(s) for specific healthcare services. In cases where the negotiated price exceeds the billed charge, Employer may be liable for the excess amount even when the member’s deductible has not been satisfied. This excess amount reflects an amount that may be necessary to secure (a) the provider’s participation in the network and/or (b) the overall discount negotiated by the Host Blue. In such a case, the entire contracted price is paid to the provider, even when the contracted price is greater than the billed charge. Claims Pricing Host Blues determine a negotiated price, which is reflected in the terms of each Host Blue’s provider contracts. The negotiated price made available to Florida Blue by the Host Blue may be represented by one of the following: • An actual price. An actual price is a negotiated rate of payment in effect at the time a claim is processed without any other increases or decreases; or • An estimated price. An estimated price is a negotiated rate of payment in effect at the time a claim is processed, reduced or increased by a percentage to take into account certain payments negotiated with the provider and other claim- and non-claim-related transactions. Such transactions may include, but are not limited to, anti-fraud and abuse recoveries, provider refunds not applied on a claim-specific basis, retrospective settlements and performance related bonuses or incentives; or • An average price. An average price is a percentage of billed covered charges in effect at the time a claim is processed representing the aggregate payments negotiated by the Host Blue with all of its healthcare providers or a similar classification of its providers and other...
Liability Calculation Method Per Claim. The calculation of the Member liability on claims for covered healthcare services processed through the BlueCard Program will be based on the lower of the participating healthcare provider's billed covered charges or the negotiated price made available to Highmark Delaware by the Host Blue. The calculation of Group's liability on claims for covered healthcare services processed through the BlueCard Program will be based on the negotiated price made available to Highmark Delaware by the Host Blue. Sometimes, this negotiated price may be greater than billed charges if the Host Blue has negotiated with its participating healthcare provider(s) an inclusive allowance (e.g., per case or per day amount) for specific healthcare services. Host Blues may use various methods to determine a negotiated price, depending on the terms of each Host Blue’s healthcare provider contracts. The negotiated price made available to Highmark Delaware by the Host Blue may represent a payment negotiated by a Host Blue with a healthcare provider that is one of the following:
Liability Calculation Method Per Claim. The calculation of Member liability on Claims for covered services processed through the BlueCard Program will be based on the lower of the provider’s billed charges or the negotiated price made available to Contractor by the Host Blue. The calculation of HCA liability on Claims for covered services processed through BlueCard will be based on the negotiated price made available to Contractor by the Host Blue. Sometimes, this negotiated price may be greater than billed charges if the Host Blue has negotiated with its participating healthcare provider(s) an inclusive allowance (e.g., per case or per day amount) for specific healthcare services.
Liability Calculation Method Per Claim. The calculation of Participant liability on claims for covered health care services incurred outside the geographic area Blue Shield serves, and processed through BlueCard will be based on the negotiated price Blue Shield pays the Host Blue. The calculation of County liability on claims for covered health care services incurred outside the geographic area Blue Shield serves, and processed through BlueCard will be based on the negotiated price Blue Shield pays the Host Blue. The methods employed by a Host Blue to determine a negotiated price will vary among Host Blues based on the terms of each Host Blue’s provider contracts. The negotiated price paid to a Host Blue by Blue Shield on a claim for health care services processed through BlueCard may represent:
Liability Calculation Method Per Claim. The calculation of Subscriber liability on claims for covered health care services incurred outside the geographic area Blue Shield of California serves, and processed through BlueCard will be based on the lower of the provider's billed charges or the negotiated price Blue Shield of California pays the Host Blue. The methods employed by a Host Blue to determine a negotiated price will vary among Host Blues based on the terms of each Host Blue’s provider contracts. The negotiated price paid to a Host Blue by Blue Shield of California on a claim for health care services processed through BlueCard may represent:
Liability Calculation Method Per Claim. Unless subject to a fixed dollar copayment, the calculation of the Member liability on claims for Covered Services will be based on the lower of the participating provider's billed charges for Covered Services or the negotiated price made available to Anthem by the Host Blue. Host Blues determine a negotiated price, which is reflected in the terms of each Host Blue’s healthcare provider contracts. The negotiated price made available to Anthem by the Host Blue may be represented by one of the following:
Liability Calculation Method Per Claim. The calculation of the member liability on claims for covered healthcare services processed through the BlueCard Program will be based on the lower of the participating healthcare provider's billed covered charges or the negotiated price made available to Florida Blue by the Host Blue. The calculation of Employer liability on claims for covered healthcare services processed through the BlueCard Program will be based on the negotiated price made available to Florida Blue by the Host Blue. Sometimes, this negotiated price may be greater than billed charges if the Host Blue has negotiated with its participating healthcare provider(s) an inclusive allowance (e.g., per case or per day amount) for specific healthcare services. Host Blues may use various methods to determine a negotiated price, depending on the terms of each Host Blue’s healthcare provider contracts. The negotiated price made available to Florida Blue by the Host Blue may represent a payment negotiated by a Host Blue with a healthcare provider that is one of the following:
