Covered Person Liability Calculation. Unless subject to a fixed dollar Copayment, the calculation of the Covered Person’s liability on Claims for Covered Services will be based on the lower of the Participating Healthcare Provider's billed charges for Covered Services or the negotiated price made available to Claim Administrator by the Host Blue.
Covered Person Liability Calculation. If BCBSNE has entered into a Negotiated National Account arrangement with a Host Blue, the Covered Person liability calculation will be based on the lower of either: billed covered charges or the negotiated price that the Host Blue makes available to BCBSNE and that allows THE GROUP’s Covered Persons access to negotiated participation agreement networks of specified participating providers outside of BCBSNE’s service area. Under certain circumstances, if BCBSNE pays the healthcare provider amounts that are the responsibility of the Covered Person BCBSNE may collect such amounts from the Covered Person. In situations where participating agreements allow for bulk settlement reconciliations for Episode- Based Payment (Bundled Payments), BCBSNE may include a factor for such settlement reconciliations as part of the fees BCBSNE charges to THE GROUP. Where THE GROUP agrees to use reference-based benefits, which are service-specific benefit dollar limits for specific procedures, based on a Host Blue’s local market rates, Covered Persons will be responsible for the amount that the healthcare provider bills for a specified procedure above the reference benefit limit for that procedure. For a participating provider, that amount will be the difference between the negotiated price and the reference benefit limit. For a nonparticipating provider, that amount will be the difference between the provider’s billed charge and the reference benefit limit. Where a reference benefit limit exceeds either a negotiated price or a provider’s billed charge, the Covered Person will incur no liability, other than any applicable Covered Person cost sharing under this Agreement.
Covered Person Liability Calculation. (1) In General When Covered Services are provided outside of Claim Administrator’s service area by Non-Participating Healthcare Providers, the amount(s) a Covered Person pays for such services will be calculated using the methodology described in the Agreement for Non-Participating Providers located inside Claim Administrator’s service area or the pricing requirements required by applicable law. The Covered Person may be responsible for the difference between the amount that the Non-Participating Healthcare Provider bills and the payment Claim Administrator will make for the Covered Services as set forth in this paragraph. Exceptions In some exception cases, Claim Administrator may, but is not required to, in its sole and absolute discretion, negotiate a payment with such Non-Participating Healthcare Provider on an exception basis.
Covered Person Liability Calculation. Unless subject to a fixed dollar Copayment, the calculation of the Covered Person’s liability on Claims for Covered Services will be based on the lower of the Participating Healthcare Provider's billed charges for Covered Services or the negotiated price made available to Claim Administrator by the Host Blue. Employer’s Liability Calculation. The calculation of Employer’s liability on Claims for Covered Services processed through the BlueCard Program will be based on the negotiated price made available to Claim Administrator by the Host Blue. Sometimes, this negotiated price may, for a particular service or services, exceed the billed charge in accordance with how the Host Blue has negotiated with its Participating Healthcare Provider(s) for specific healthcare services. In cases where the negotiated price exceeds the billed charge, Employer may be liable for the excess amount even when the Covered Person’s deductible has not been satisfied. This excess amount reflects an amount that may be necessary to secure (a) the Provider’s participation in the Network and/or (b) the overall discount negotiated by the Host Blue. In such a case, the entire contracted price is paid to the Provider, even when the contracted price is greater than the billed charge.
Covered Person Liability Calculation i. In General When Covered Services are provided outside of BCBSNE service area by nonparticipating providers, the amount a Covered Person 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 state law. In these situations, the Covered Person may be responsible for the difference between the amount that the nonparticipating provider bills and the payment BCBSNE will make for the Covered Services as set forth in this paragraph. Payments for out-of-network emergency services will be governed by applicable federal and state law.
