Common use of Claims Pricing Clause in Contracts

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 BCBSNE by the Host Blue may be represented by one of the following: i. 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 ii. 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 iii. An average price. An average price is a percentage of billed charges for Covered Services 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 claim- and non-claim- related transactions. Such transactions may include the same ones as noted above for an estimated price. The Host Blue determines whether it will use an actual, estimated or average price. The use of estimated or average pricing may result in a difference (positive or negative) between the price THE GROUP pays on a specific claim and the actual amount the Host Blue pays to the provider. However, the BlueCard Program requires that the amount paid by the Covered Person and THE GROUP is a final price; no future price adjustment will result in increases or decreases to the pricing of past claims. Any positive or negative differences in estimated or average pricing are accounted for through variance accounts maintained by the Host Blue and are incorporated into future claim prices. As a result, the amounts charged to THE GROUP will be adjusted in a following year, as necessary, to account for over- or underestimation of the past years’ prices. The Host Blue will not receive compensation from how the estimated price or average price methods, described above, are calculated. Because all amounts paid are final, neither positive variance account amounts (funds available to be paid in the following year), nor negative variance amounts (the funds needed to be received in the following year), are due to or from THE GROUP. If THE GROUP terminates, THE GROUP will not receive a refund or charge from the variance account. Variance account balances are small amounts relative to the overall paid claims amounts and will be liquidated over time. The timeframe for their liquidation depends on variables, including, but not limited to, overall volume (number of claims processed) and variance account balance. Variance account balances may earn interest at the federal funds or similar rate. Host Blues may retain interest earned on funds held in variance accounts.

Claims Pricing. Host Blues determine a negotiated price, which is reflected in the terms of each Host Blue’s provider Participating Provider contracts. The negotiated price made available to BCBSNE Anthem by the Host Blue may be represented by one of the following: i. (i) An actual price. An actual price is a negotiated rate of payment in effect at the time a claim Claim is processed without any other increases or decreases; or (ii. ) An estimated price. An estimated price is a negotiated rate of payment in effect at the time a claim Claim is processed, reduced or increased by a percentage to take into account certain payments negotiated with the provider Provider and other claim- Claim- and non-claimClaim-related transactions. Such transactions may include, but are not limited to, anti-fraud and abuse recoveries, provider Provider refunds not applied on a claimClaim-specific basis, retrospective settlements and performance- performance-related bonuses or incentives; or (iii. ) An average price. An average price is a percentage of billed charges for Covered Services Billed Charges in effect at the time a claim Claim is processed representing the aggregate payments negotiated by the Host Blue with all of its healthcare providers Participating Providers or a similar classification of its providers Participating Providers and other claim- Claim- and non-claim- Claim-related transactions. Such transactions may include the same ones as noted above for an estimated price. The Host Blue determines whether it will use an actual, estimated or average price. The use of estimated or average pricing may result in a difference (positive or negative) between the price THE GROUP Employer pays on a specific claim Claim and the actual amount the Host Blue pays to the providerParticipating Provider. However, the BlueCard Program requires that the amount paid by the Covered Person and THE GROUP is be a final price; no future price adjustment will result in increases or decreases to the pricing of past claimsClaims. Any positive or negative differences in estimated or average pricing are accounted for through variance accounts maintained by the Host Blue and are incorporated into future claim Claim prices. As a result, the amounts charged to THE GROUP Employer will be adjusted in a following year, as necessary, to account for over- or underestimation under-estimation of the past years’ prices. The Host Blue will not receive compensation from how the estimated price or average price methods, described above, are calculated. Because all amounts paid are final, neither positive variance account amounts (funds available to be paid in the following year), nor negative variance amounts (the funds needed to be received in the following year), are due to or from THE GROUPEmployer. If THE GROUP terminatesUpon termination, THE GROUP Employer will not receive a refund or charge from the variance account. Variance account balances are small amounts relative to the overall paid claims Claims amounts and will be liquidated over time. The timeframe for their liquidation depends on variables, including, but not limited to, overall volume (volume/number of claims processed) Claims processed and variance account balance. Variance account balances may earn interest at the federal funds or similar rate. Host Blues may retain interest earned on funds held in variance accounts.

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 BCBSNE Wellmark by the Host Blue may be represented by one of the following: i. a) 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 ii. b) 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 settlements, and performance- related bonuses or incentives; or iii. c) An average price. An average price is a percentage of billed charges for Out-of-Area Covered Services in effect at the time a claim is processed representing the aggregate payments negotiated by the Host Blue with all of its healthcare health care providers or a similar classification of its providers and other claim- and non-claim- related transactions. Such transactions may include the same ones as noted above for an estimated price. The Host Blue determines whether it will use an actual, estimated estimated, or average price. The use Host Blues using either an estimated price or an average price may prospectively increase or reduce such prices to correct for over- or underestimation of estimated past prices (i.e., prospective adjustment may mean that a current price reflects additional amounts or average pricing may result in a difference (positive credits for claims already paid to providers or negative) between the price THE GROUP pays on a specific claim and the actual amount the Host Blue pays anticipated to the providerbe paid to or refunds received or anticipated to be received from providers). However, the BlueCard BlueCard® Program requires that the amount paid by the Covered Person and THE GROUP Member is a final price; no future price adjustment will result in increases or decreases to the pricing of past claims. Any positive The method of claims payment by Host Blues is taken into account by Xxxxxxxx in determining Account’s premiums. In some instances federal or negative differences in estimated state laws or average pricing are accounted for through variance accounts maintained by the Host Blue and are incorporated into future claim prices. As regulations may impose a resultsurcharge, the amounts charged to THE GROUP will be adjusted in a following year, as necessary, to account for over- tax or underestimation of the past years’ prices. The Host Blue will not receive compensation from how the estimated price or average price methods, described above, are calculated. Because all amounts paid are final, neither positive variance account amounts (funds available to be paid in the following year), nor negative variance amounts (the funds needed to be received in the following year), are due to or from THE GROUPother fee. If THE GROUP terminatesapplicable, THE GROUP Wellmark will not receive a refund include any such surcharge, tax or charge from the variance account. Variance account balances are small amounts relative to the overall paid claims amounts and will be liquidated over time. The timeframe for their liquidation depends on variables, including, but not limited to, overall volume (number of claims processed) and variance account balance. Variance account balances may earn interest at the federal funds or similar rate. Host Blues may retain interest earned on funds held other fee in variance accountsdetermining Account’s premium.

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 BCBSNE Claims Administrator by the Host Blue may be represented by one of the following: i. 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 ii. 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-claim- specific basis, retrospective settlements and performance- performance-related bonuses or incentives; or iii. An average price. An average price is a percentage of billed covered charges for Covered Services 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 claim- and non-claim- claim-related transactions. Such transactions may include the same ones as noted above for an estimated price. The Host Blue determines whether it will use an actual, estimated or average price. The use of estimated or average pricing may result in a difference (positive or negative) between the price THE GROUP Employer pays on a specific claim and the actual amount the Host Blue pays to the provider. However, the BlueCard Program requires that the amount paid by the Covered Person member and THE GROUP Employer is a final price; no future price adjustment will result in increases or decreases to the pricing of past claims. Any positive or negative differences in estimated or average pricing are accounted for through variance accounts maintained by the Host Blue and are incorporated into future claim prices. As a result, the amounts charged to THE GROUP Employer will be adjusted in a following year, as necessary, to account for over- or underestimation of the past years’ prices. The Host Blue will not receive compensation from how the estimated price or average price methods, described above, are calculated. Because all amounts paid are final, neither positive variance account amounts (funds available to be paid in the following year), nor negative variance amounts (the funds needed to be received in the following year), are due to or from THE GROUPEmployer. If THE GROUP Employer terminates, THE GROUP you will not receive a refund or charge from the variance account. Variance account balances are small amounts relative to the overall paid claims amounts and will be liquidated over time. The timeframe for their liquidation depends on variables, including, but not limited to, overall volume (volume/number of claims processed) processed and variance account balance. Variance account balances may earn interest at the federal funds or similar rate. Host Blues may retain interest earned on funds held in variance accounts.

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 BCBSNE Wellmark by the Host Blue may be represented by one of the following: i. a) 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 ii. b) 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 settlements, and performance- related bonuses or incentives; or iii. c) An average price. An average price is a percentage of billed charges for Out-of-Area Covered Services in effect at the time a claim is processed representing the aggregate payments negotiated by the Host Blue with all of its healthcare health care providers or a similar classification of its providers and other claim- and non-claim- related transactions. Such transactions may include the same ones as noted above for an estimated price. The Host Blue determines whether it will use an actual, estimated estimated, or average price. The use Host Blues using either an estimated price or an average price may prospectively increase or reduce such prices to correct for over- or underestimation of estimated past prices (i.e., prospective adjustment may mean that a current price reflects additional amounts or average pricing may result in a difference (positive credits for claims already paid to providers or negative) between the price THE GROUP pays on a specific claim and the actual amount the Host Blue pays anticipated to the providerbe paid to or refunds received or anticipated to be received from providers. However, the BlueCard BlueCard® Program requires that the amount paid by the Covered Person and THE GROUP Member is a final price; no future price adjustment will result in increases or decreases to the pricing of past claims. Any positive The method of claims payment by Host Blues is taken into account by Xxxxxxxx in determining Account’s premiums. In some instances federal or negative differences in estimated state laws or average pricing are accounted for through variance accounts maintained by the Host Blue and are incorporated into future claim prices. As regulations may impose a resultsurcharge, the amounts charged to THE GROUP will be adjusted in a following year, as necessary, to account for over- tax or underestimation of the past years’ prices. The Host Blue will not receive compensation from how the estimated price or average price methods, described above, are calculated. Because all amounts paid are final, neither positive variance account amounts (funds available to be paid in the following year), nor negative variance amounts (the funds needed to be received in the following year), are due to or from THE GROUPother fee. If THE GROUP terminatesapplicable, THE GROUP Wellmark will not receive a refund include any such surcharge, tax or charge from the variance account. Variance account balances are small amounts relative to the overall paid claims amounts and will be liquidated over time. The timeframe for their liquidation depends on variables, including, but not limited to, overall volume (number of claims processed) and variance account balance. Variance account balances may earn interest at the federal funds or similar rate. Host Blues may retain interest earned on funds held other fee in variance accountsdetermining Account’s premium.

Claims Pricing. The Host Blues determine Blue determines a negotiated price, which is reflected in the terms of each Host Blue’s provider healthcare Provider contracts. The negotiated price made available to BCBSNE BCBSM by the Host Blue may be represented by one of the following: i. An (i) an actual price. An actual price is a negotiated rate of payment in effect at the time a claim Claim is processed without any other increases or decreases; , or (ii. An ) an estimated price. An estimated price is a negotiated rate of payment in effect at the time a claim Claim is processed, reduced or increased by a percentage to take into account certain payments negotiated with the provider Provider and other claim- Claim- and non-claimClaim-related transactions. Such transactions may include, but are not limited to, anti-anti- fraud and abuse recoveries, provider Provider refunds not applied on a claimClaim-specific basis, retrospective settlements settlements, and performance- performance-related bonuses or incentives; , or (iii. An ) an average price. An average price is a percentage of billed charges for Covered Services covered services in effect at the time a claim Claim is processed representing the aggregate payments negotiated by the Host Blue with all of its healthcare providers Providers or a similar classification of its providers Providers and other claim- Claim- and non-claim- Claim-related transactions. Such transactions may include the same ones as noted above for an estimated price. The Host Blue determines whether it will use an actual, estimated or an average priceprice in its respective Provider agreements. The use of estimated or average pricing may result in a difference (positive or negative) between the price THE GROUP Group pays on a specific claim Claim and the actual amount the Host Blue pays to the providerProvider. However, the BlueCard Program requires that the amount paid by the Covered Person Enrollee and THE GROUP Group is a final price; no future price adjustment will result in increases or decreases to the pricing of past claimsClaims. Any positive or negative differences in estimated or average pricing are accounted for through variance accounts maintained by the Host Blue and are incorporated into future claim Claim prices. As a result, the amounts charged to THE GROUP Group will be adjusted in a following year, as necessary, to account for over- or underestimation of the past years’ prices. The Host Blue will not receive compensation from how the estimated price or average price methods, described above, are calculated. Because all amounts paid are final, neither positive variance account amounts (funds available to be paid in the following year), nor negative variance amounts (the funds needed to be received in the following year), are due to or from THE GROUPGroup. If THE GROUP Group terminates, THE GROUP Group will not receive a refund or charge from the variance account. Variance account balances are small amounts relative to the overall paid claims Claims amounts and will be liquidated liquidated/drawn down over time. The timeframe for their liquidation depends on variables, including, but not limited to, overall volume (/ number of claims processed) Claims processed and variance account balance. Variance account balances may earn interest at the federal funds or similar rate. The Host Blues Blue may retain interest earned on funds held in variance accounts.

Claims Pricing. Host Blues determine a negotiated price, which is reflected in the terms of each Host Blue’s provider Provider contracts. The negotiated price made available to BCBSNE Claim Administrator by the Host Blue may be represented by one of the following: i. : An actual price. An actual price is a negotiated rate of payment in effect at the time a claim Claim is processed without any other increases or decreases; or ii. or An estimated price. An estimated price is a negotiated rate of payment in effect at the time a claim Claim is processed, reduced or increased by a percentage to take into account certain payments negotiated with the provider Provider and other claim- Claim- and non-claimClaim-related transactions. Such transactions may include, but are not limited to, anti-fraud and abuse recoveries, provider Provider refunds not applied on a claimClaim-specific basis, retrospective settlements settlements, and performance- performance-related bonuses or incentives; or iii. or An average price. An average price is a percentage of billed charges for Covered Services in effect at the time a claim Claim is processed representing the aggregate payments negotiated by the Host Blue with all of its healthcare providers Providers or a similar classification of its providers Providers and other claim- Claim- and non-claim- Claim-related transactions. Such transactions may include the same ones as noted above for an estimated price. The Host Blue determines whether it will use an actual, estimated or an average price. The use of estimated or average pricing may result in a difference (positive or negative) between the price THE GROUP Employer pays on a specific claim Claim and the actual amount the Host Blue pays to the providerProvider. However, the BlueCard Program requires that the amount paid by the Covered Person and THE GROUP Employer is a final price; no future price adjustment will result in increases or decreases to the pricing of past claimsClaims. Any positive or negative differences in estimated or average pricing are accounted for through variance accounts maintained by the Host Blue and are incorporated into future claim Claim prices. As a result, the amounts charged to THE GROUP Employer will be adjusted in a following year, as necessary, to account for over- or underestimation under-estimation of the past years’ prices. The Host Blue will not receive compensation from how the estimated price or average price methods, described above, are calculated. Because all amounts paid are final, neither positive variance account amounts (funds available to be paid in the following year), nor negative variance amounts (the funds needed to be received in the following year), are due to or from THE GROUPEmployer. If THE GROUP Employer terminates, THE GROUP Employer will not receive a refund or charge from the variance account. Variance account balances are small amounts relative to the overall paid claims Claims amounts and will be liquidated liquidated/drawn down over time. The timeframe for their the liquidation depends on variables, including, but not limited to, overall volume (volume/number of claims processed) Claims processed and variance account balance. Variance account balances may earn interest at the federal funds or similar rate. Host Blues may retain interest earned on funds held in variance accounts.