Common use of Coverage for Services Provided Clause in Contracts

Coverage for Services Provided. Outside Our Service Area Overview BCBSRI has a variety of relationships with other Blue Cross and/or Blue Shield Licensees. Generally, these relationships are called “Inter-Plan Arrangements.” These Inter-Plan Arrangements work based on rules and procedures issued by the Blue Cross and Blue Shield Association (“Association”). Whenever you access healthcare services outside the geographic area BCBSRI serves, the claim for those services may be processed through one of these Inter-Plan Arrangements, as described below. When you receive care outside of the BCBSRI service area, you will receive it from one of two kinds of providers. Most providers (“participating providers”) contract with the local Blue Cross and/or Blue Shield Plan in that geographic area (“Host Blue”). Some providers (“nonparticipating providers”) don’t contract with the Host Blue. We explain below how we pay both kinds of providers. This plan covers only limited healthcare services received outside of the service area. As used in this section, “Out-of-Area covered healthcare services” include the following services obtained outside the geographic area we serve: Emergency care (emergency room, urgent care center and ambulance services); services for which we specifically approve the use of a non-network provider; and otherwise, as required by law. Any other services will not be covered when processed through any Inter-Plan Arrangements unless authorized by us. Inter-Plan Arrangements Eligibility – Claim Types All claim types are eligible to be processed through Inter-Plan Arrangements, as described above, except for all dental benefits, and those prescription drug benefits or vision benefits that may be administered by a third party contracted by us to provide the specific service or services. BlueCard® Program Under the BlueCard® Program, when you receive covered healthcare services within the geographic area served by a Host Blue, BCBSRI will remain responsible for doing what we agreed to in the contract. However, the Host Blue is responsible for contracting with and generally handling all interactions with its participating providers. When you receive covered healthcare services outside our service area and the claim is processed through the BlueCard Program, the amount you pay for covered healthcare services is calculated based on the lower of: • the billed covered charges for your covered services; or • the negotiated price that the Host Blue makes available to BCBSRI. The BlueCard Program enables you to obtain Out-of-Area covered healthcare services, as defined above, from a healthcare provider participating with a Host Blue, where available. The participating provider will automatically file a claim for the Out-of-Area Covered healthcare services provided to you, so there are no claim forms for you to fill out. You will be responsible for the copayment amount, as stated in the Summary of Benefits.

Coverage for Services Provided. Outside Our Service Area Overview BCBSRI has a variety of relationships with other Blue Cross and/or Blue Shield Licensees. Generally, these relationships are called “Inter-Plan Arrangements.” These Inter-Plan Arrangements work based on rules and procedures issued by the Blue Cross and Blue Shield Association (“Association”). Whenever you access healthcare services outside the geographic area BCBSRI serves, the claim for those services may be processed through one of these Inter-Plan Arrangements, as described below. When you receive care outside of the BCBSRI service area, you will receive it from one of two kinds of providers. Most providers (“participating providers”) contract with the local Blue Cross and/or Blue Shield Plan in that geographic area (“Host Blue”). Some providers (“nonparticipating providers”) don’t contract with the Host Blue. We explain below how we pay both kinds of providers. This plan covers only limited healthcare services received outside of the Network Blue New England service area. As used in this section, “Out-of-Area covered healthcare services” include the following services obtained outside the geographic area we serve: Emergency care (emergency room, urgent care center and ambulance services); services for which we specifically approve the use of a non-network provider; and otherwise, as required by law. Any other services will not be covered when processed through any Inter-Plan Arrangements unless authorized by us. Inter-Plan Arrangements Eligibility – Claim Types All claim types are eligible to be processed through Inter-Plan Arrangements, as described above, except for all dental benefits, and those prescription drug benefits or vision benefits that may be administered by a third party contracted by us to provide the specific service or services. BlueCard® Program Under the BlueCard® Program, when you receive covered healthcare services within the geographic area served by a Host Blue, BCBSRI will remain responsible for doing what we agreed to in the contract. However, the Host Blue is responsible for contracting with and generally handling all interactions with its participating providers. When you receive covered healthcare services outside our service area and the claim is processed through the BlueCard Program, the amount you pay for covered healthcare services is calculated based on the lower of: • the billed covered charges for your covered services; or • the negotiated price that the Host Blue makes available to BCBSRI. The BlueCard Program enables you to obtain Out-of-Area covered healthcare services, as defined above, from a healthcare provider participating with a Host Blue, where available. The participating provider will automatically file a claim for the Out-of-Area Covered healthcare services provided to you, so there are no claim forms for you to fill out. You will be responsible for the copayment amount, as stated in the Summary of Benefits.

Coverage for Services Provided. Outside Our Service Area Overview BCBSRI has a variety of relationships with other Blue Cross and/or Blue Shield Licensees. Generally, these relationships are called “Inter-Plan Arrangements.” These Inter-Plan Arrangements work based on rules and procedures issued by the Blue Cross and Blue Shield Association (“Association”). Whenever you access healthcare services outside the geographic area BCBSRI serves, the claim for those services may be processed through one of these Inter-Plan Arrangements, as described below. When you receive care outside of the BCBSRI service area, you will receive it from one of two kinds of providers. Most providers (“participating providers”) contract with the local Blue Cross and/or Blue Shield Plan in that geographic area (“Host Blue”). Some providers (“nonparticipating providers”) don’t contract with the Host Blue. We explain below how we pay both kinds of providers. This plan covers only limited healthcare services received outside of the BlueCHiP Direct service area. As used in this section, “Out-of-Area covered healthcare services” include the following services obtained outside the geographic area we serve: Emergency care (emergency room, urgent care center and ambulance services); services for which we specifically approve the use of a non-network provider; and otherwise, as required by law. Any other services will not be covered when processed through any Inter-Plan Arrangements Arrangements, including Blue Cross Blue Shield Global® Core, unless authorized by us. Inter-Plan Arrangements Eligibility – Claim Types All claim types are eligible to be processed through Inter-Plan Arrangements, as described above, except for all dental benefits, and those prescription drug benefits or vision benefits that may be administered by a third party contracted by us to provide the specific service or services. BlueCard® Program Under the BlueCard® Program, when you receive covered healthcare services within the geographic area served by a Host Blue, BCBSRI will remain responsible for doing what we agreed to in the contract. However, the Host Blue is responsible for contracting with and generally handling all interactions with its participating providers. When you receive covered healthcare services outside our service area and the claim is processed through the BlueCard Program, the amount you pay for covered healthcare services is calculated based on the lower of: • the billed covered charges for your covered services; or • the negotiated price that the Host Blue makes available to BCBSRI. The BlueCard Program enables you to obtain Out-of-Area covered healthcare services, as defined above, from a healthcare provider participating with a Host Blue, where available. The participating provider will automatically file a claim for the Out-of-Area Covered healthcare services provided to you, so there are no claim forms for you to fill out. You will be responsible for the copayment amount, as stated in the Summary of Benefits.

Coverage for Services Provided. Outside Our Service Area Overview BCBSRI has a variety of relationships with other Blue Cross and/or Blue Shield Licensees. Generally, these relationships are called “Inter-Plan Arrangements.” These Inter-Plan Arrangements work based on rules and procedures issued by the Blue Cross and Blue Shield Association (“Association”). Whenever you access healthcare services outside the geographic area BCBSRI serves, the claim for those services may be processed through one of these Inter-Plan Arrangements, as described below. When you receive care outside of the BCBSRI service area, you will receive it from one of two kinds of providers. Most providers (“participating providers”) contract with the local Blue Cross and/or Blue Shield Plan in that geographic area (“Host Blue”). Some providers (“nonparticipating providers”) don’t contract with the Host Blue. We explain below how we pay both kinds of providers. This plan covers only limited healthcare services received outside of the Network Blue New England service area. As used in this section, “Out-of-Area covered healthcare services” include the following services obtained outside the geographic area we serve: Emergency care (emergency room, urgent care center and ambulance services); services for which we specifically approve the use of a non-network provider; and otherwise, as required by law. Any other services will not be covered when processed through any Inter-Plan Arrangements unless authorized by us. Inter-Plan Arrangements Eligibility – Claim Types All claim types are eligible to be processed through Inter-Plan Arrangements, as described above, except for all dental benefits, and those prescription drug benefits or vision benefits that may be administered by a third party contracted by us to provide the specific service or services. BlueCard® Program Under the BlueCard® Program, when you receive covered healthcare services within the geographic area served by a Host Blue, BCBSRI will remain responsible for doing what we agreed to in the contract. However, the Host Blue is responsible for contracting with and generally handling all interactions with its participating providers. When you receive covered healthcare services outside our service area and the claim is processed through the BlueCard Program, the amount you pay for covered healthcare services is calculated based on the lower of: • the billed covered charges for your covered services; or • the negotiated price that the Host Blue makes available to BCBSRI. The BlueCard Program enables you to obtain Out-of-Area covered healthcare services, as defined above, from a healthcare provider participating with a Host Blue, where available. The participating provider will automatically file a claim for the Out-of-Area Covered healthcare services provided to you, so there are no claim forms for you to fill out. You will be responsible for the copayment amount, as stated in the Summary of Benefits.

Coverage for Services Provided. Outside Our Service Area Overview BCBSRI has a variety of relationships with other Blue Cross and/or Blue Shield Licensees. Generally, these relationships are called “Inter-Plan Arrangements.” These Inter-Plan Arrangements work based on rules and procedures issued by the Blue Cross and Blue Shield Association (“Association”). Whenever you access healthcare services outside the geographic area BCBSRI serves, the claim for those services may be processed through one of these Inter-Plan Arrangements, as described below. When you receive care outside of the BCBSRI service area, you will receive it from one of two kinds of providers. Most providers (“participating providers”) contract with the local Blue Cross and/or Blue Shield Plan in that geographic area (“Host Blue”). Some providers (“nonparticipating providers”) don’t contract with the Host Blue. We explain below how we pay both kinds of providers. This plan covers only limited healthcare services received outside of the our service area. As used in this section, . “Out-of-Area covered healthcare services” include the following services obtained outside the geographic area we serve: Emergency care (emergency room, urgent care center and ambulance services); services for which we specifically approve the use of a non-network provider; and otherwise, as required by law. Any other services will not be covered when processed through any Inter-Plan Arrangements unless authorized by us. Inter-Plan Arrangements Eligibility – Claim Types All claim types are eligible to be processed through Inter-Plan Arrangements, as described above, except for all dental benefits, and those prescription drug benefits or vision benefits that may be administered by a third party contracted by us to provide the specific service or services. BlueCard® Program Under the BlueCard® Program, when you receive covered healthcare services within the geographic area served by a Host Blue, BCBSRI will remain responsible for doing what we agreed to in the contract. However, the Host Blue is responsible for contracting with and generally handling all interactions with its participating providers. When you receive covered healthcare services outside our service area and the claim is processed through the BlueCard Program, the amount you pay for covered healthcare services is calculated based on the lower of: • the billed covered charges for your covered services; or • the negotiated price that the Host Blue makes available to BCBSRI. The BlueCard Program enables you to obtain Out-of-Area covered healthcare services, as defined above, from a healthcare provider participating with a Host Blue, where available. The participating provider will automatically file a claim for the Out-of-Area Covered healthcare services provided to you, so there are no claim forms for you to fill out. You will be responsible for the copayment amount, as stated in the Summary of Benefits.

Coverage for Services Provided. Outside Our Service Area Overview BCBSRI has a variety of relationships with other Blue Cross and/or Blue Shield Licensees. Generally, these relationships are called “Inter-Plan Arrangements.” These Inter-Plan Arrangements work based on rules and procedures issued by the Blue Cross and Blue Shield Association (“Association”). Whenever you access healthcare services outside the geographic area BCBSRI serves, the claim for those services may be processed through one of these Inter-Plan Arrangements, as described below. When you receive care outside of the BCBSRI service area, you will receive it from one of two kinds of providers. Most providers (“participating providers”) contract with the local Blue Cross and/or Blue Shield Plan in that geographic area (“Host Blue”). Some providers (“nonparticipating providers”) don’t contract with the Host Blue. We explain below how we pay both kinds of providers. This plan covers only limited healthcare services received outside of the our service area. As used in this section, . “Out-of-Area covered Covered healthcare services” include the following services obtained outside the geographic area we serve: Emergency care (emergency room, urgent care center room services and ambulance services); services for which we specifically approve the use of a non-network participating provider; and otherwise, as required by law. Any other services will not be covered when processed through any Inter-Plan Arrangements unless authorized by us. Inter-Plan Arrangements Eligibility – Claim Types All claim types are eligible to be processed through Inter-Plan Arrangements, as described above, except for all dental benefits, and those prescription drug benefits or vision benefits that may be administered by a third party contracted by us to provide the specific service or services. BlueCard® Program Under the BlueCard® Program, when you receive covered healthcare services within the geographic area served by a Host Blue, BCBSRI will remain responsible for doing what we agreed to in the contract. However, the Host Blue is responsible for contracting with and generally handling all interactions with its participating providers. When you receive covered healthcare services outside our service area and the claim is processed through the BlueCard Program, the amount you pay for covered healthcare services is calculated based on the lower of: • the billed covered charges for your covered services; or • the negotiated price that the Host Blue makes available to BCBSRI. The BlueCard Program enables you to obtain Out-of-Area covered Covered healthcare services, as defined above, from a healthcare provider participating with a Host Blue, where available. The participating provider will automatically file a claim for the Out-of-Area Covered healthcare services provided to you, so there are no claim forms for you to fill out. You will be responsible for the copayment amount, as stated in the Summary of Benefits.

Coverage for Services Provided. Outside Our Service Area Overview BCBSRI has a variety of relationships with other Blue Cross and/or Blue Shield Licensees. Generally, these relationships are called “Inter-Plan Arrangements.” These Inter-Plan Arrangements work based on rules and procedures issued by the Blue Cross and Blue Shield Association (“Association”). Whenever you access healthcare services outside the geographic area BCBSRI serves, the claim for those services may be processed through one of these Inter-Plan Arrangements, as described below. When you receive care outside of the BCBSRI service area, you will receive it from one of two kinds of providers. Most providers (“participating providers”) contract with the local Blue Cross and/or Blue Shield Plan in that geographic area (“Host Blue”). Some providers (“nonparticipating providers”) don’t contract with the Host Blue. We explain below how we pay both kinds of providers. This plan covers only limited healthcare services received outside of the Network Blue New England service area. As used in this section, “Out-of-Area covered healthcare services” include the following services obtained outside the geographic area we serve: Emergency care (emergency room, urgent care center and ambulance services); services for which we specifically approve the use of a non-network provider; and otherwise, as required by law. Any other services will not be covered when processed through any Inter-Plan Arrangements unless authorized by us. Inter-Plan Arrangements Eligibility – Claim Types All claim types are eligible to be processed through Inter-Plan Arrangements, as described above, except for all dental benefits, and those prescription drug benefits or vision benefits that may be administered by a third party contracted by us to provide the specific service or services. BlueCard® Program Under the BlueCard® Program, when you receive covered healthcare services within the geographic area served by a Host Blue, BCBSRI will remain responsible for doing what we agreed to in the contract. However, the Host Blue is responsible for contracting with and generally handling all interactions with its participating providers. When you receive covered healthcare services outside our service area and the claim is processed through the BlueCard Program, the amount you pay for covered healthcare services is calculated based on the lower of: •  the billed covered charges for your covered services; or •  the negotiated price that the Host Blue makes available to BCBSRI. The BlueCard Program enables you to obtain Out-of-Area covered healthcare services, as defined above, from a healthcare provider participating with a Host Blue, where available. The participating provider will automatically file a claim for the Out-of-Area Covered healthcare services provided to you, so there are no claim forms for you to fill out. You will be responsible for the copayment amount, as stated in the Summary of Benefits.

Coverage for Services Provided. Outside Our Service Area Overview BCBSRI has a variety of relationships with other Blue Cross and/or Blue Shield Licensees. Generally, these relationships are called “Inter-Plan Arrangements.” These Inter-Plan Arrangements work based on rules and procedures issued by the Blue Cross and Blue Shield Association (“Association”). Whenever you access healthcare services outside the geographic area BCBSRI serves, the claim for those services may be processed through one of these Inter-Plan Arrangements, as described below. When you receive care outside of the BCBSRI service area, you will receive it from one of two kinds of providers. Most providers (“participating providers”) contract with the local Blue Cross and/or Blue Shield Plan in that geographic area (“Host Blue”). Some providers (“nonparticipating providers”) don’t contract with the Host Blue. We explain below how we pay both kinds of providers. This plan covers only limited healthcare services received outside of the service area. As used in this section, “Out-of-Area covered healthcare services” include the following services obtained outside the geographic area we serve: Emergency care (emergency room, urgent care center and ambulance services); services for which we specifically approve the use of a non-network provider; and otherwise, as required by law. Any other services will not be covered when processed through any Inter-Plan Arrangements Arrangements, unless authorized by us. Inter-Plan Arrangements Eligibility – Claim Types All claim types are eligible to be processed through Inter-Plan Arrangements, as described above, except for all dental benefits, and those prescription drug benefits or vision benefits that may be administered by a third party contracted by us to provide the specific service or services. BlueCard® Program Under the BlueCard® Program, when you receive covered healthcare services within the geographic area served by a Host Blue, BCBSRI will remain responsible for doing what we agreed to in the contract. However, the Host Blue is responsible for contracting with and generally handling all interactions with its participating providers. When you receive covered healthcare services outside our service area and the claim is processed through the BlueCard Program, the amount you pay for covered healthcare services is calculated based on the lower of: • the billed covered charges for your covered services; or • the negotiated price that the Host Blue makes available to BCBSRI. The BlueCard Program enables you to obtain Out-of-Area covered healthcare services, as defined above, from a healthcare provider participating with a Host Blue, where available. The participating provider will automatically file a claim for the Out-of-Area Covered healthcare services provided to you, so there are no claim forms for you to fill out. You will be responsible for the copayment amount, as stated in the Summary of Benefits.

Coverage for Services Provided. Outside Our Service Area Overview BCBSRI has a variety of relationships with other Blue Cross and/or Blue Shield Licensees. Generally, these relationships are called “Inter-Plan Arrangements.” These Inter-Plan Arrangements work based on rules and procedures issued by the Blue Cross and Blue Shield Association (“Association”). Whenever you access healthcare services outside the geographic area BCBSRI serves, the claim for those services may be processed through one of these Inter-Plan Arrangements, as described below. When you receive care outside of the BCBSRI service area, you will receive it from one of two kinds of providers. Most providers (“participating providers”) contract with the local Blue Cross and/or Blue Shield Plan in that geographic area (“Host Blue”). Some providers (“nonparticipating providers”) don’t contract with the Host Blue. We explain below how we pay both kinds of providers. This plan covers only limited healthcare services received outside of the service area. As used in this section, “Out-of-Area covered healthcare services” include the following services obtained outside the geographic area we serve: Emergency care (emergency room, urgent care center and ambulance services); services for which we specifically approve the use of a non-network provider; and otherwise, as required by law. Any other services will not be covered when processed through any Inter-Plan Arrangements unless authorized by us. Inter-Plan Arrangements Eligibility – Claim C–laim Types All claim types are eligible to be processed through Inter-Plan Arrangements, as described above, except for all dental benefits, and those prescription drug benefits or vision benefits that may be administered by a third party contracted by us to provide the specific service or services. BlueCard® Program Under the BlueCard® Program, when you receive covered healthcare services within the geographic area served by a Host Blue, BCBSRI will remain responsible for doing what we agreed to in the contract. However, the Host Blue is responsible for contracting with and generally handling all interactions with its participating providers. When you receive covered healthcare services outside our service area and the claim is processed through the BlueCard Program, the amount you pay for covered healthcare services is calculated based on the lower of: • the billed covered charges for your covered services; or • the negotiated price that the Host Blue makes available to BCBSRI. The Often, this “negotiated price” will be a simple discount that reflects an actual price that the Host Blue pays to your healthcare provider. Sometimes, it is an estimated price that takes into account special arrangements with your healthcare provider or provider group that may include types of settlements, incentive payments and/or other credits or charges. Occasionally, it may be an average price, based on a discount that results in expected average savings for similar types of healthcare providers after taking into account the same types of transactions as with an estimated price. Estimated pricing and average pricing also take into account adjustments to correct for over- or underestimation of past pricing of claims, as noted above. However, such adjustments will not affect the price we have used for your claim because they will not be applied after a claim has already been paid. Negotiated (non B–lueCard Program) Arrangements With respect to one or more Host Blues, in certain instances,instead of using the BlueCard Program enables you to obtain Out-of-Area Program, we may process your claims for covered healthcare services, as defined services through Negotiated Arrangements for National Accounts. The amount you pay for covered healthcare services under this arrangement will be calculated based on the negotiated price (refer to the description of negotiated price in the BlueCard® Program section above, from a healthcare provider participating with a ) made available to us by the Host Blue, where available. The participating provider will automatically file a claim for the Out-of-Area Covered healthcare services provided to you, so there are no claim forms for you to fill out. You will be responsible for the copayment amount, as stated in the Summary of Benefits.

Coverage for Services Provided. Outside Our Service Area Overview BCBSRI has a variety of relationships with other Blue Cross and/or Blue Shield Licensees. Generally, these relationships are called “Inter-Plan Arrangements.” These Inter-Plan Arrangements work based on rules and procedures issued by the Blue Cross and Blue Shield Association (“Association”). Whenever you access healthcare services outside the geographic area BCBSRI serves, the claim for those services may be processed through one of these Inter-Plan Arrangements, as described below. When you receive care outside of the BCBSRI service area, you will receive it from one of two kinds of providers. Most providers (“participating providers”) contract with the local Blue Cross and/or Blue Shield Plan in that geographic area (“Host Blue”). Some providers (“nonparticipating providers”) don’t contract with the Host Blue. We explain below how we pay both kinds of providers. This plan covers only limited healthcare services received outside of the BlueCHiP Direct Advance service area. As used in this section, “Out-of-Area covered healthcare services” include the following services obtained outside the geographic area we serve: Emergency care (emergency room, urgent care center and ambulance services); services for which we specifically approve the use of a non-network provider; and otherwise, as required by law. Any other services will not be covered when processed through any Inter-Plan Arrangements Arrangements, including Blue Cross Blue Shield Global® Core, unless authorized by us. Inter-Plan Arrangements Eligibility – Claim Types All claim types are eligible to be processed through Inter-Plan Arrangements, as described above, except for all dental benefits, and those prescription drug benefits or vision benefits that may be administered by a third party contracted by us to provide the specific service or services. BlueCard® Program Under the BlueCard® Program, when you receive covered healthcare services within the geographic area served by a Host Blue, BCBSRI will remain responsible for doing what we agreed to in the contract. However, the Host Blue is responsible for contracting with and generally handling all interactions with its participating providers. When you receive covered healthcare services outside our service area and the claim is processed through the BlueCard Program, the amount you pay for covered healthcare services is calculated based on the lower of: • the billed covered charges for your covered services; or • the negotiated price that the Host Blue makes available to BCBSRI. The BlueCard Program enables you to obtain Out-of-Area covered healthcare services, as defined above, from a healthcare provider participating with a Host Blue, where available. The participating provider will automatically file a claim for the Out-of-Area Covered healthcare services provided to you, so there are no claim forms for you to fill out. You will be responsible for the copayment amount, as stated in the Summary of Benefits.