For network providers. When a covered service is received from a network provider, the eligible service expense is the contracted fee with that provider. The contracted fee will be paid directly to the network provider.
For network providers. For a Provider who has a written agreement with Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide care to a Covered Person at the time Covered Services for medical benefits are rendered (“Network Provider”), the contracting Allowable Amount is based on the terms of the Network Provider’s contract and the payment methodology in effect on the date of the Covered Service. The payment methodology used may include diagnosis-related groups (DRG), fee schedule, package pricing, global pricing, per diems, case-rates, discounts, or other payment methodologies.
For network providers. A Network Provider is a Provider who has a written agreement with Claim Administrator or another Blue Cross and/or Blue Shield Plan for compensation terms for care provided to a Covered Person at the time Covered Services for medical benefits are rendered (“Network Provider”). The Allowable Amount for Network Providers is based on the compensation terms of the Network Provider’s contract and the payment methodology in effect on the date of the Covered Service. The payment methodologies used include fixed fee schedules, per unit fee schedules, diagnosis-related groups (DRG), per diems, case rates, package pricing, global pricing, discounts off eligible billed charge, or other payment methodologies. Claim Administrator claim processing rules and/or edits may also alter the Allowable Amount for particular services.
