Common use of Covered Person and Employer Liability Calculation Clause in Contracts

Covered Person and Employer Liability Calculation. Covered Person liability calculation will be based on the lower of either billed charges for Covered Services or negotiated price (refer to the description of negotiated price under Section 4.2.a., BlueCard Program) that the Host Blue makes available to Claim Administrator and that allows Employer’s Covered Persons access to negotiated participation agreement Networks of specified Participating Healthcare Providers outside of Claim Administrator’s service area. Employer’s liability calculation will be based on the negotiated price (refer to the description of negotiated price under Section 4.2.a, BlueCard Program). Employer acknowledges that pursuant to the Host Blue’s contracts with Host Blues’ Participating Healthcare Providers, under certain circumstances described therein, the Host Blue (i) may receive substantial payment from Host Blues’ Participating Healthcare Providers with respect to services rendered to such Covered Persons for which the Host Blue was initially obligated to pay the Host Blues’ Participating Healthcare Providers, (ii) may pay Host Blues’ Participating Healthcare Providers more or less than their billed charges for services, by discounts or otherwise, or (iii) may receive from Host Blues’ Participating Healthcare Providers other allowances under the Host Blue’s contracts with them. One example of this is quality improvement programs/payments. If charged by the Host Blue to Claim Administrator, Employer shall reimburse Claim Administrator for any payments made to the Host Blue, unless otherwise set forth in the Agreement’s Fee Schedule, including “Claim-like” charges, which are those charges for payments to Host Blues’ Participating Healthcare Providers on other than a fee for services basis which include, but are not limited to, incentive payments. Employer acknowledges that, in negotiating the Administrative Charge set forth in the Agreement’s Fee Schedule, it has taken into consideration that, among other things, the Host Blue may receive such payments, discounts and/or other allowances during the term of its agreement with Claim Administrator. Further, all amounts payable by Covered Person and Employer shall be calculated on the basis described in this subsection, irrespective of any separate financial arrangement between the Host Blue’s Participating Healthcare Provider that rendered the applicable Covered Service and the Host Blue other than the negotiated price as described in this subsection.

Covered Person and Employer Liability Calculation. Covered Person liability calculation will be based on the lower of either billed charges for Covered Services or negotiated price (refer to the description of negotiated price under Section 4.2.a15.2.a., BlueCard Program) that the Host Blue makes available to Claim Administrator and that allows Employer’s Covered Persons access to negotiated participation agreement Networks of specified Participating Healthcare Providers outside of Claim Administrator’s service area. Employer’s liability calculation will be based on the negotiated price (refer to the description of negotiated price under Section 4.2.a15.2.a, BlueCard Program). Employer acknowledges that pursuant to the Host Blue’s contracts with Host Blues’ Participating Healthcare Providers, under certain circumstances described therein, the Host Blue (i) may receive substantial payment from Host Blues’ Participating Healthcare Providers with respect to services rendered to such Covered Persons for which the Host Blue was initially obligated to pay the Host Blues’ Participating Healthcare Providers, (ii) may pay Host Blues’ Participating Healthcare Providers more or less than their billed charges for services, by discounts or otherwise, or (iii) may receive from Host Blues’ Participating Healthcare Providers other allowances under the Host Blue’s contracts with them. One example of this is quality improvement programs/payments. If charged by the Host Blue to Claim Administrator, Employer shall reimburse Claim Administrator for any payments made to the Host Blue, unless otherwise set forth in the Agreement’s Fee Schedule, including “Claim-like” charges, which are those charges for payments to Host Blues’ Participating Healthcare Providers on other than a fee for services basis which include, but are not limited to, incentive payments. Employer acknowledges that, in negotiating the Administrative Charge Fee set forth in the Agreement’s Fee Schedule, it has taken into consideration that, among other things, the Host Blue may receive such payments, discounts and/or other allowances during the term of its agreement with Claim Administrator. Further, all amounts payable by Covered Person and Employer shall be calculated on the basis described in this subsection, irrespective of any separate financial arrangement between the Host Blue’s Participating Healthcare Provider that rendered the applicable Covered Service and the Host Blue other than the negotiated price as described in this subsection.