Enrollee Cost Transparency. The Exchange and Contractor acknowledge and agree that information relating to the cost of procedures and services is important to enrollees, the Exchange, the Contractor and providers. The Exchange also understands that Contractor negotiates Agreements with providers, including dental practice groups and other clinical providers, which may result in varied provider reimbursement levels for identical services and or procedures. In the event that Contractor’s provider contracts result in different provider reimbursement levels that have an impact on Plan Enrollee costs within a specific region, as defined by paid claims for CDT services, Contractor agrees to provide the Exchange with its plan, measures and process to assist Plan Enrollees in identifying total cost and out-of-pocket cost information for the highest frequency and highest cost service(s) and or procedure(s). When available, this pricing information shall be prominently displayed and made available to both Plan Enrollees and contracted Contractor providers if provided. This information shall be updated on at least an annual basis unless there is a contractual change that would change enrollee out-of-pocket costs by more than 10%. In that case, information must be updated within 30 days of the effective date of the new contract.
Enrollee Cost Transparency. The Exchange and Contractor acknowledge and agree that information relating to the cost of procedures and services is important to enrollees, the Exchange, the Contractor and providers. The Exchange also understands that Contractor negotiates Agreements with providers, including physicians, hospitals, physician groups and other clinical providers, which may result in varied provider reimbursement levels for identical services and or procedures. In the event that Contractor’s provider contracts result in different provider reimbursement levels that have an impact on Plan Enrollee costs within a specific region, as defined by paid claims for like CPT, ICD9/10 and DRG based services, Contractor agrees to provide the Exchange with its plan, measures and process to assist Plan Enrollees identify total cost and out-of-pocket cost information for the highest frequency and highest cost service(s) and or procedure(s). When available, this pricing information shall be prominently displayed and made available to both Plan Enrollees and contracted Contractor providers if provided. This information shall be updated on at least an annual basis unless there is a contractual change that would change enrollee out-of-pocket costs by more than 10%. In that case, information must be updated within 30 days of the effective date of the new contract.
Enrollee Cost Transparency. The Exchange and Contractor acknowledge and agree that information relating to the cost of procedures and services is important to enrollees, the Exchange, the Contractor and providers. The Exchange also understands that Contractor negotiates Agreements with providers, including physicians, hospitals, physician groups and other clinical providers, which may or may not result in varied provider reimbursement levels for identical services and or procedures. In the event that Contractor’s provider contracts do result in different provider reimbursement levels that have an impact on Plan Enrollee out of pocket costs within a specific region, as defined by paid claims for like CPT, ICD9/10 and DRG based services: (1) Contractor agrees to provide the Exchange with its plan, measures and process to assist Plan Enrollees identify total cost and out-of-pocket cost information for the highest frequency and highest cost service(s) and or procedure(s); (2) when available, this pricing information shall be prominently displayed and made available to both Plan Enrollees and contracted Contractor providers if provided; and (3) this information shall be updated on at least an annual basis; provided however, if there is a contractual change that would change enrollee out-of-pocket costs by more than 10%, information must be updated within 30 days of the effective date of the new contract.
Enrollee Cost Transparency. Covered California and Contractor acknowledge and agree that information relating to the cost of procedures and services is important to Enrollees, Covered California, the Contractor, and Providers. Covered California also understands that Contractor negotiates Agreements with Providers, including dental practice groups and other clinical providers, which may result in varied Provider reimbursement levels for identical services or procedures. In the event that Contractor’s Provider contracts result in different Provider reimbursement levels that have an impact on Plan Enrollee costs within a specific region, as defined by paid claims for Current Dental Terminology (CDT) services, Contractor agrees to provide Covered California with its plan, measures, and process to assist Plan Enrollees in identifying total cost and out-of-pocket cost information for the highest frequency and highest cost service(s) and or procedure(s). When available, this pricing information shall be prominently displayed and made available to both Plan Enrollees and contracted Contractor Providers if provided. This information shall be updated on at least an annual basis unless there is a contractual change that would change enrollee out-of-pocket costs by more than 10%. In that case, information must be updated within thirty (30) days of the effective date of the new contract.
