Health Care Services Furnished Outside of Massachusetts. Blue Cross and Blue Shield has a variety of relationships with other Blue Cross and/or Blue Shield Licensees referred to generally as “Inter-Plan Programs.” Whenever Members access health care services outside of Massachusetts, the claim for those services may be processed through one of these Inter-Plan Programs and presented to Blue Cross and Blue Shield for payment. The Inter-Plan Programs available to Members under this Agreement are described generally below. Typically, Members accessing care outside of Massachusetts obtain care from providers that have a contractual agreement (that is, are “participating providers”) with the local Blue Cross and/or Blue Shield Licensee in that other geographic area (referred to in this Agreement as Host Plan or local Blue Cross and/or Blue Shield Plan). In some instances, Members may obtain care from non-participating providers. Members’ health care benefits for participating and non-participating providers are fully described in the Subscriber Certificates for your benefits plans. The BlueCard® Program Under the BlueCard Program, when Members access covered health care services in a geographic area served by a Host Plan, Blue Cross and Blue Shield will remain responsible for fulfilling the obligations of this Agreement. The Host Plan will be responsible for providing such services as contracting with its participating providers and handling substantially all interactions with its participating providers and, as applicable, providing some managed care services.
Health Care Services Furnished Outside of Massachusetts. Blue Cross and Blue Shield has a variety of relationships with other Blue Cross and/or Blue Shield Licensees referred to generally as “Inter-Plan Programs.” Whenever Members access health care services outside of Massachusetts, the claim for those services may be processed through one of these Inter-Plan Programs and presented to Blue Cross and Blue Shield for payment in compliance with the Inter-Plan Programs policies then in effect. The Inter-Plan Programs available to Members under this Agreement are described generally below. Typically, Members accessing care outside of Massachusetts obtain care from providers that have a contractual agreement (that is, are “participating providers”) with the local Blue Cross and/or Blue Shield Licensee in that other geographic area (Host Plan or local Blue Cross and/or Blue Shield Plan). In some instances, Members may obtain care from non-participating providers. Members’ health care benefits for participating and non-participating providers are fully described in the Subscriber Certificates for your benefits plans.
Health Care Services Furnished Outside of Massachusetts. The BlueCard® Program. Blue Cross and Blue Shield participates in a program called BlueCard. Whenever Members access health care services outside of Massachusetts, the claim for those services may be processed through BlueCard and presented to Blue Cross and Blue Shield for payment in compliance with the BlueCard Program. Under BlueCard, when Members receive covered health care services in a geographic area served by a Host Blue Cross and/or Blue Shield Licensee (Host Plan), Blue Cross and Blue Shield will remain responsible for fulfilling the obligations of this Agreement. The Host Plan will be responsible only for providing services such as contracting with its participating providers, handling all interaction with its participating providers and, as applicable, some managed care services. The methods used by a Host Plan to determine a negotiated price will vary among Host Plans based on the terms of each Host Plan’s provider contracts. The negotiated price that Blue Cross and Blue Shield pays to a Host Plan on a claim for covered health care services processed through BlueCard may represent: • The actual price paid on the claim by the Host Plan to the health care provider; or • An estimated price, determined by the Host Plan in accordance with the BlueCard Program, based on the actual price increased or reduced to reflect aggregate payments expected to result from settlements, withholds, any other contingent payment arrangements and non-claims transactions (such as provider advances) with all of the Host Plan’s health care providers or with one or more particular providers; or • An average price, determined by the Host Plan in accordance with the BlueCard Program, based on a billed charges discount that represents the Host Plan’s average savings expected after settlements, withholds, any other contingent payment arrangements and non-claims transactions (such as provider advances) with all of the Host Plan’s health care providers or with one or more specific groups of providers. An average price may result in greater variation to the Member and the Account from the actual price than would an estimated price. Those Host Plans that use either the estimated price or average price will, in accordance with the BlueCard Program, prospectively increase or reduce the estimated price or average price to correct for over- or underestimation of past prices. However, the amount paid by the Member is a final price and will not be affected by this prospective adjustme...
Health Care Services Furnished Outside of Massachusetts. The BlueCard® Program. Blue Cross and Blue Shield participates in a program called BlueCard. Whenever Members access health care services outside of Massachusetts, the claim for those services may be processed through BlueCard and presented to Blue Cross and Blue Shield for payment in compliance with the BlueCard Program. Under BlueCard, when Members receive covered health care services in a geographic area served by a Member Liability Calculation. The calculation of a Member’s liability on claims for covered health care services received outside of Massachusetts and processed through BlueCard will be based on the provider’s actual charge or the negotiated price (allowed charge), whichever is less. Return of Overpayments. Under BlueCard, recoveries from a Host Plan or from participating providers of a Host Plan can arise in several ways. These may include (but are not limited to) anti-fraud and abuse audits, provider/hospital audits, credit balance audits, utilization review refunds and unsolicited refunds. In some cases, the Host Plan will engage third parties to assist in discovery or collection of recovery amounts. The fees of any such third party are subtracted from the recovery. Recovery amounts (net of fees), if any, will be applied, in accordance with the BlueCard Program, which generally requires correction on a claim-by-claim or prospective basis.
