Member Liability Calculation. The calculation of a Member’s liability on claims for covered health care services received outside of Massachusetts and processed through the BlueCard Program will be based on the provider’s actual charge or the negotiated price (allowed charge), whichever is less. The methods used 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 that a Host Plan passes on to Blue Cross and Blue Shield for a claim for covered health care services processed through BlueCard may represent: • The actual price paid on the claim by the Host Plan to the health care provider; or • An estimated price, determined by the Host Plan in accordance with the BlueCard Program, based on the actual price increased or reduced to reflect aggregate payments expected to result from settlements, withholds, other contingent payment arrangements, and other claim- and non-claim-related transactions (such as interest on provider advances) with all of the Host Plan’s health care providers or with one or more particular providers; or • An average price, determined by the Host Plan in accordance with the BlueCard Program, based on a billed charges discount that represents the Host Plan’s average savings expected after settlements, withholds, other contingent payment arrangements, and other claim- and non-claim-related transactions (such as interest on provider advances) with all of the Host Plan’s health care providers or with one or more specific groups of providers. An average price may result in greater variation to the Member and the Account from the actual price than would an estimated price. Those Host Plans that use either the estimated price or average price may, in accordance with the BlueCard Program, prospectively increase or reduce the estimated price or average price to correct for over- or underestimation of past prices (that is, prospective adjustment may mean that a current price reflects additional amounts or credits for claims already paid to or received from providers). However, the amount paid by the Member is a final price and no future price adjustment will result in increases or decreases to the pricing of past claims. The BlueCard Program requires that the price submitted by a Host Plan to Blue Cross and Blue Shield is a final price irrespective of any future adjustments based on the use of estimated or average pricing. Statutes in a small number of states may require a Host...
Member Liability Calculation. When Out-of-Area Covered Healthcare Services are provided outside of the BCN Service Area by nonparticipating providers, the amount(s) you pay for such services will generally be based on either the Host Blue’s nonparticipating provider local payment or the pricing arrangements required by applicable state law. In these situations, you may be responsible for the difference between the amount that the nonparticipating healthcare provider bills and the payment BCN will make for Out-of-Area Covered Healthcare Services as set forth in this paragraph. Payments for out-of-network emergency services will be governed by applicable federal and state law.
Member Liability Calculation. When you receive Covered Services outside of our service area from a Medicare Advantage PPO network provider, the cost of the service, on which member liability (copayment/coinsurance) is based, will be either: • The Medicare allowable amount for covered services; or • The amount either we negotiate with the provider or the Host Blue negotiates with its provider on behalf of our members, if applicable. The amount negotiated may be either higher than, lower than, or equal to the Medicare allowable amount.
Member Liability Calculation. 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 or the negotiated price made available to Anthem by the Host Blue.
Member Liability Calculation. If Anthem has entered into a Negotiated Arrangement with a Host Blue, the calculation of Member cost-sharing will be based on the lower of either Billed Charges or negotiated price (refer to the description of negotiated price under Section A, BlueCard Program) that the Host Blue makes available to Anthem and that allows Members access to negotiated participation agreement networks of specified Participating Providers outside of Anthem's service area.
Member Liability Calculation. When covered services are provided outside of CareFirst service area by non-participating providers, the amount you pay for such services will normally be based on either the Host Blue’s non-participating provider local payment or the pricing arrangements required by applicable state law. In these situations, you may be responsible for the difference between the amount that the non-participating provider bills and the payment CareFirst will make for the covered services as set forth in this paragraph. Federal or state law, as applicable, will govern payments for out-of-network emergency services.
Member Liability Calculation. When a Member receives Covered Services outside of the MA Plan service area from a Medicare Advantage PPO network provider, the cost of the service, on which Member liability (copayment/coinsurance) is based will be either: • The Medicare allowable amount for covered services; or • The amount either Vendor negotiates with the provider or the negotiates with its provider on behalf of MA Plan Members, if applicable. The amount negotiated may be either higher than, lower than, or equal to the Medicare allowable amount.
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.
Member Liability Calculation. 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 BlueCross by the Host Blue. DocuSign Envelope ID: CD93B45A-0105-43E7-9602-5AE5EB65AF29 DocuSign Envelope ID: 00C2B362-1FE5-4A7F-86FB-24039505711D
Member Liability Calculation. 1.5.1.1. In General When Covered Services are provided outside of BlueCross’s service area by nonparticipating providers, the amount(s) a Member pays for such services will be based on either the Host Blue’s nonparticipating healthcare provider local payment or the pricing arrangements required by applicable law. In these situations, the Member may be responsible for the difference between the amount that the nonparticipating provider bills and the payment BlueCross will make for the Covered Services as set forth in this paragraph. Payments for certain out-of-network services, including out-of-network emergency services will be governed by applicable federal and state law.
