Common use of Emergency Services and Urgent Care Clause in Contracts

Emergency Services and Urgent Care. If Members receive Emergency Services or Urgent Care from a Provider outside of Keystone’s Limited Network Area, and the Provider is a Member of the local Blue Plan, Members should show their ID card to the Provider. The Provider will file a claim with the local Blue Plan that will in turn electronically route the claim to Keystone for processing. Keystone applies the applicable benefits and Cost-Sharing Amounts to the claim. This information is then sent back to the local Blue Plan that will in turn make payment directly to the Participating Provider – after applicable Cost-Sharing Amounts, if any, have been applied. ALLOWABLE AMOUNT For Professional Providers and Facility Providers, the benefit payment amount is based on the Allowable Amount on the date the service is rendered. Benefit payments to Hospitals or other Facility Providers may be adjusted from time to time based on settlements with such Providers. Such adjustments will not affect the Member’s Cost-Sharing Amount obligations. FILING A CLAIM If it is necessary for Members to submit a claim to Keystone, they should be sure to request an itemized xxxx from their health care Provider. The itemized xxxx should be submitted to Keystone with a completed Keystone Health Plan Central Claim Form. Members can obtain a copy of the Keystone Health Plan Central Claim Form by contacting Customer Service or visiting the Member link on Keystone’s website at xxxxxxxxxxxx.xxx. The Member’s claim will be processed more quickly when the Keystone Health Plan Central Claim Form is used. A separate claim form must be completed for each Member who received medical services. Members should include all of the following information with their claim:

Emergency Services and Urgent Care. If Members receive Emergency Services or Urgent Care from a Provider outside of Keystone’s Limited Network Approved Service Area, and the Provider is a Member of the local Blue Plan, Members should show their ID card to the Provider. The Provider will file a claim with the local Blue Plan that will in turn electronically route the claim to Keystone for processing. Keystone applies the applicable benefits and Cost-Sharing Amounts to the claim. This information is then sent back to the local Blue Plan that will in turn make payment directly to the Participating Provider – after applicable Cost-Sharing Amounts, if any, have been applied. ALLOWABLE AMOUNT AMOUNT‌ For Professional Providers and Facility Providers, the benefit payment amount is based on the Allowable Amount on the date the service is rendered. Benefit payments to Hospitals or other Facility Providers may be adjusted from time to time based on settlements with such Providers. Such adjustments will not affect the Member’s Cost-Sharing Amount obligations. FILING A CLAIM CLAIM‌ If it is necessary for Members to submit a claim to Keystone, they should be sure to request an itemized xxxx bill from their health care Provider. The itemized xxxx bill should be submitted to Keystone with a completed Keystone Health Plan Central Claim Form. Members can obtain a copy of the Keystone Health Plan Central Claim Form by contacting Customer Service or visiting the Member link on Keystone’s website at xxxxxxxxxxxx.xxx. The Member’s claim will be processed more quickly when the Keystone Health Plan Central Claim Form is used. A separate claim form must be completed for each Member who received medical services. Members should include all of the following information with their claim:

Emergency Services and Urgent Care. If Members receive Emergency Services or Urgent Care from a Provider outside of Keystone’s Limited Network Eligibility & Service Area, and the Provider is a Member of the local Blue Plan, Members should show their ID card to the Provider. The Provider will file a claim with the local Blue Plan that will in turn electronically route the claim to Keystone for processing. Keystone applies the applicable benefits and Cost-Sharing Amounts to the claim. This information is then sent back to the local Blue Plan that will in turn make payment directly to the Participating Provider – after applicable Cost-Sharing Amounts, if any, have been applied. ALLOWABLE AMOUNT AMOUNT‌ For Professional Providers and Facility Providers, the benefit payment amount is based on the Allowable Amount on the date the service is rendered. Benefit payments to Hospitals or other Facility Providers may be adjusted from time to time based on settlements with such Providers. Such adjustments will not affect the Member’s Cost-Sharing Amount obligations. FILING A CLAIM CLAIM‌ If it is necessary for Members to submit a claim to Keystone, they should be sure to request an itemized xxxx bill from their health care Provider. The itemized xxxx bill should be submitted to Keystone with a completed Keystone Health Plan Central Claim Form. Members can obtain a copy of the Keystone Health Plan Central Claim Form by contacting Customer Service or visiting the Member link on Keystone’s website at xxxxxxxxxxxx.xxx. The Member’s claim will be processed more quickly when the Keystone Health Plan Central Claim Form is used. A separate claim form must be completed for each Member who received medical services. Members should include all of the following information with their claim:

Emergency Services and Urgent Care. If Members receive Emergency Services or Urgent Care from a Provider outside of Keystone’s Limited Network Approved Service Area, and the Provider is a Member of the local Blue Plan, Members should show their ID card to the Provider. The Provider will file a claim with the local Blue Plan that will in turn electronically route the claim to Keystone for processing. Keystone applies the applicable benefits and Cost-Sharing Amounts to the claim. This information is then sent back to the local Blue Plan that will in turn make payment directly to the Participating Provider – after applicable Cost-Sharing Amounts, if any, have been applied. ALLOWABLE AMOUNT For Professional Providers and Facility Providers, the benefit payment amount is based on the Allowable Amount on the date the service is rendered. Benefit payments to Hospitals or other Facility Providers may be adjusted from time to time based on settlements with such Providers. Such adjustments will not affect the Member’s Cost-Sharing Amount obligations. FILING A CLAIM If it is necessary for Members to submit a claim to Keystone, they should be sure to request an itemized xxxx bill from their health care Provider. The itemized xxxx bill should be submitted to Keystone with a completed Keystone Health Plan Central Claim Form. Members can obtain a copy of the Keystone Health Plan Central Claim Form by contacting Customer Service or visiting the Member link on Keystone’s website at xxxxxxxxxxxx.xxx. The Member’s claim will be processed more quickly when the Keystone Health Plan Central Claim Form is used. A separate claim form must be completed for each Member who received medical services. Members should include all of the following information with their claim: