For non-network providers a. When a covered service is received from a non-network provider as a result of an emergency and there is not a network provider reasonably accessible to render the covered service, the eligible service expense is the lesser of (1) the negotiated fee, if any, that has been mutually agreed upon by us and the provider as payment in full (you will not be billed for the difference between the negotiated fee and the provider’s charge), or (2) the provider’s billed charge.;
b. When a covered service is received from a non-network provider as a result of an emergency and there is a network provider reasonably accessible to render the covered service, the eligible service expense is the negotiated fee, if any, that the provider has agreed to accept as payment in full (you will not be billed for the difference between the negotiated fee and the provider’s charge). However, if the provider has not agreed to accept a negotiated fee as payment in full, the eligible expense is the greatest of the following:
i. the amount that would be paid under Medicare,
ii. the amount for the covered service calculated using the same method we generally use to determine payments for out-of-network services, or
iii. the contracted amount paid to network providers for the covered service. If there is more than one contracted amount with network providers for the covered service, the amount is the median of these amounts.
c. When a covered service is received from a non-network provider as approved or authorized by us, the eligible service expense is the negotiated fee, if any, that the provider has agreed to accept as payment in full (you will not be billed for the difference between the negotiated fee and the provider’s charge). ). If there is no negotiated fee agreed to by the provider with us, the eligible service expense is the greater of (1) the amount that would be paid by Medicare, or (2) the contracted amount paid to network providers for the covered service. If there is more than one contracted amount with network providers for the covered service, the amount is the median of these amounts. You may be billed for the difference between the amount paid and the provider’s charge.
d. When a covered service expense is received from a non-network provider because the service or supply is not of a type provided by any network provider, the eligible service expense is the negotiated fee, if any, that the provider has agreed to accept as payment in full (you will not be billed for the...
For non-network providers. For a Provider who does not have 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 (“Non- Network Provider”), the Allowable Amount will be the lesser of:
1. the Non-Network Provider's Claim Charge, or;
For non-network providers. For a Provider who does not have 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 (“Non- Network Provider”), the Allowable Amount for Non-Network Providers is developed from base Medicare reimbursements, excluding any Medicare adjustments using information on the Claim, and adjusted by a predetermined factor established by the Plan. Such factor will not be less than one-hundred percent (100%) of the base Medicare reimbursement rate unless a lower factor has been negotiated with the Non-Network Provider. For services for which a Medicare reimbursement rate is not available, the Allowable Amount for Non- Network Providers will represent an average contract rate for Network Providers adjusted by a predetermined factor established by the Plan and updated on a periodic basis. Such factor shall not be less than eighty percent (80%) of the average contract rates and will be updated not less than every two years. Claim Administrator will utilize the same Claim processing rules and/or edits that it utilizes in processing Network Provider Claims for processing Claims submitted by Non-Network Providers which may also alter the Allowable Amount for a particular service. In the event the Plan does not have any Claim edits or rules, the Plan may utilize the Medicare claim rules or edits that are used by Medicare in processing the Claims. The Allowable Amount will not include any additional payments that may be permitted under the Medicare laws or regulations which are not directly attributable to a specific Claim, including but not limited to, disproportionate share and graduate medical education payments. Any change to the Medicare reimbursement amount will be implemented by the Plan within ninety (90) days after the effective date that such change is implemented by the Centers for Medicaid and Medicare Services, or its successor.
