Allowable Charge. The lesser of the submitted charge or the amount established by the Contractor, as provided through Provider Network contracts or based on analysis of Provider charges, as the maximum amount for all such Provider services covered under the terms of this Contract.
Allowable Charge. For Preferred Providers and Participating Providers - The lesser of the billed charge or the amount We establish or negotiate as the maximum amount allowed for services from these all Providers services covered under the terms of this Contract.
Allowable Charge. To take full advantage of the negotiated pricing arrangements in effect between Blue Cross and Blue Shield of Oklahoma and our network of Participating Dentists, you should use Participating Dentists whenever possible. Participating Dentists have agreed to hold the line on dental care costs by providing special prices for our Subscribers. A Participating Dentist will accept this negotiated price (called the “Allowable Charge”) as payment for Covered Services. This means that, if a Participating Dentist bills you more than the Allowable Charge for Covered Services, you are not responsible for the difference. The Plan will calculate your Benefits based on this “Allowable Charge”. We will deduct any charges for services which aren’t eligible under your coverage, then subtract your Deductible and/or Coinsurance amounts which may be applicable to your Covered Dental Services, as set forth in the Schedule of Benefits. We will then determine your Benefits under this Contract and direct any payment to your Participating Dentist. If you use an Out-of-Network Dentist, you will be responsible for the following: • Charges for any services which are not covered under your Contract; • Any Deductible and/or Coinsurance amounts which are applicable to your coverage; and • The difference, if any, between your Dentist's “billed charges” and the “Allowable Charge”. Your coverage may include a higher Deductible and/or Coinsurance percentage for services you receive from an Out-of-Network Provider (check the Schedule of Benefits issued with this Contract). Some Benefits are limited to a specific dollar amount or number of services or visits allowed during a Benefit Period. Your Benefit Period is a Calendar Year, which begins on January 1st and ends on December 31st of the same year. The initial Benefit Period begins on your Effective Date and ends on December 31st, which may be less than 12 months. Your Policy Year and Benefit Period run concurrently.
Allowable Charge. The charge the Claims Administrator will use as the basis for Benefit determination for Covered Services Incurred by a Covered Person under this Plan. The Claims Administrator will use the following criteria to establish the Allowable Charge:
Allowable Charge. For a charge to be allowable, it must be a Usual Customary and Reasonable Charge and at least part of it must be covered under this Plan. In the case of an HMO or other in- network-only plans, this Plan will not consider any charges in excess of what the HMO or Network Provider has agreed to accept as payment in full. When an HMO or in-network-only plan is primary and the Covered Person does not use the HMO or Network Provider, this Plan will not consider as an Allowable Charge any charge that would have been covered by the HMO or in-network-only plan had the Covered Person used the services of an HMO or Network Provider. In the case of service type plans where services are provided as benefits, the reasonable cash value of each service will be the Allowable Charge.
Allowable Charge. The charge the Claims Administrator will use as the basis for Benefit determination for Covered Services Incurred by a Covered Person under this Plan. The Claims Administrator will use the following criteria to establish the Allowable Charge:
a. Delta Dental Premier Participating Dentists − the Dentist’s submitted fee up to the amount the Claims Administrator determines to be the maximum allowable amount for Delta Dental Premier Participating Dentists in the geographic area where the Covered Services were rendered.
Allowable Charge. The following allowable charges have been established for the DoD Enhanced Access to Autism Services Demonstration (XXX, Chapter 20, Section 10):
(a) EIA services provided directly to a beneficiary by an EIA Supervisor, inclusive of those services provided when an EIA Tutor or an EIA Tutor-in-Training is present, will be invoiced by the ICSP or OCSP using HCPCS code “S5108, Home care training to home care client, per 15 minutes.” The maximum allowable charge for S5108 is $21.25 per each 15 minute increment.
(b) EIA services provided directly by an EIA Tutor to a beneficiary will be invoiced by the ICSP or OCSP using HCPCS code “H2019, Therapeutic behavioral services, per 15 minutes.” The maximum allowable charge for H2019 is $9.00 per each 15 minute increment.
(c) EIA practical training of family members by an EIA Supervisor will be invoiced by the ICSP or OCSP using HCPCS code “S5110, Home care training, family, per 15 minutes.” The maximum allowable charge for S5110 is $21.25 per each 15 minute increment.
(d) In accordance with the TRICARE Policy Manual (TPM), Chapter 9, Section 8.1, claims for EIA classroom training of parent(s)/caregiver(s) will be reimbursed when submitted to the appropriate Managed Care Support Contractor (MCSC) by the sponsor of the beneficiary enrolled in the Demonstration.
Allowable Charge. An Allowable Charge for a network Provider means the negotiated fee/rate set forth in the agreement with the participating network health Provider, facility, or organization and the Plan. The Allowable Charge for a non-network Provider means the amount as determined by the Board of Trustees that the Plan will pay for a particular service or supply. The Plan will pay Allowable Charges for out-of-network services or supplies only as determined by the Board of Trustees or its designee. Allowable Charges means the charges that are typically made for services and supplies in the geographic area based on the complexity of treatment received. Amounts that exceed the Allowable Charge will not apply toward the calendar year deductible or out-of-pocket maximum. Association means the Louisville Chapter of the National Electrical Contractors Association, Inc.
Allowable Charge. The term “
Allowable Charge. The lesser of the billed charge or the amount established by Xxxxx Vision as the maximum amount allowed for all Provider services covered under the terms of this Benefit Plan. Appeal – A request from a Member or authorized representative to change a previous decision made by the Company about Covered Services. Authorization (Authorized) – A determination by Xxxxx Vision that, based on the information provided, a Benefit satisfies the clinical review criteria requirement for Medical Necessity, appropriateness of the health care setting, or level of care and effectiveness. An Authorization is not a guarantee of payment. Benefit(s) – Coverage for the benefits as described in Article IV and the Schedule of Vision Benefits. Benefits provided by the Company are based on the Allowable Charge.
