Inter-Plan Programs. Federal/State Taxes/Surcharges/Fees
Inter-Plan Programs. Blue Shield has a variety of relationships with other Blue Cross and/or Blue Shield plans and their Licensed Controlled Affiliates (“Licensees”) referred to generally as “Inter-Plan Programs.” Whenever you obtain healthcare services outside of California, the claims for these services may be processed through one of these Inter-Plan Pro- grams. When you access Covered Services outside of Cal- ifornia you may obtain care from healthcare providers that have a contractual agreement (i.e., are “participating providers”) with the local Blue Cross and/or Blue Shield Licensee in that other ge- ographic area (“Host Plan”). In some instances, you may obtain care from non-participating healthcare providers. Blue Shield’s payment prac- tices in both instances are described in this EOC. Under the BlueCard® Program, when you obtain Covered Services within the geographic area served by a Host Plan, Blue Shield will remain re- sponsible for fulfilling our contractual obligations. However the Host Blue is responsible for contract- ing with and generally handling all interactions with its participating healthcare providers. The BlueCard Program enables you to obtain Cov- Often, this “negotiated price” will be a simple dis- count that reflects an actual price that the Host Plan pays to your healthcare provider. Sometimes, it is an estimated price that takes into account special arrangements with your healthcare provider or provider group that may include types of settle- ments, incentive payments, and/or other credits or charges. Occasionally, it may be an average price, based on a discount that results in expected aver- age savings for similar types of healthcare providers after taking into account the same types of transactions as with an estimated price. Estimated pricing and average pricing, going for- xxxx, also take into account adjustments to correct for over- or underestimation of modifications of past pricing for the types of transaction modifica- tions noted above. However, such adjustments will not affect the price Blue Shield uses for your claim because they will not be applied retroactively to claims already paid. Laws in a small number of states may require the Host Plan to add a surcharge to your calculation. If any state laws mandate other liability calculation methods, including a surcharge, we would then calculate your liability for any covered healthcare services according to applicable law. Claims for covered Emergency Services are paid based on the Allo...
Inter-Plan Programs. Blue Shield has a variety of relationships with other Blue Cross and/or Blue Shield Plans and their Licensed Controlled Affiliates (“Licensees”) referred to generally as “Inter-Plan Programs.” Whenever you obtain healthcare services outside of California, the claims for these services may be processed through one of these Inter-Plan Programs. When you access Covered Services outside of California you may obtain care from healthcare providers that have a contractual agreement (i.e., are “participating providers”) with the local Blue Cross and/or Blue Shield Licensee in that other geographic area (“Host Plan”). In some instances, you may obtain care from non-participating healthcare providers. Blue Shield’s payment practices in both instances are described in this booklet. Under the BlueCard® Program, when you obtain Covered Services within the geographic area served by a Host Plan, Blue Shield will remain responsible for fulfilling our contractual obligations. However the Host Blue is responsible for contracting with and generally handling all interactions with its participating healthcare providers. The BlueCard Program enables you to obtain Covered Services outside of California, as defined, from a healthcare provider participating with a Host Plan, where available. The participating healthcare provider will automatically file a claim for the Covered Services provided to you, so there are no claim forms for you to fill out. You will be responsible for the member copayment and deductible amounts, if any, as stated in this Evidence of Coverage. Whenever you access Covered Services outside of California and the claim is processed through the BlueCard Program, the amount you pay for covered healthcare services, if not a flat dollar copayment, is calculated based on the lower of:
Inter-Plan Programs. BCBSND has a variety of relationships with other Blue Cross and/or Blue Shield Licensees referred to generally as "Inter-Plan Programs." Whenever a Member accesses health care services outside of the geographic area BCBSND serves, the claim for those services may be processed through one of these Inter-Plan Programs and presented to BCBSND for payment in accordance with the rules of the Inter- Plan Programs policies then in effect. The Inter-Plan Programs available to Members under this Agreement are described generally below. Typically, when accessing care outside the BCBSND service area, a Member will obtain care from health care providers that have a contractual agreement (i.e., "participating agreement") with the local Blue Cross and/or Blue Shield Licensee in that other geographic area ("Host Blue"). In some instances, a Member may obtain care from health care providers who have not entered into a "participating agreement" with a Host Blue. BCBSND payment practices in both instances are described below.
A. BlueCard® Program
1. the actual price. An actual price is a negotiated payment without any other increases or decreases; or
2. an estimated price. An estimated price is a negotiated payment reduced or increased by a percentage to take into account certain payments negotiated with the provider and other claim- and non-claim-related transactions. Such transactions may include, but are not limited to, anti- fraud and abuse recoveries, provider refunds not applied on a claim-specific basis, retrospective settlements, and performance-related bonuses or incentives; or
3. an average price. An average price is a percentage of billed covered charges representing the aggregate payments negotiated by the Host Blue with all of its health care providers or a similar classification of its providers and other claim- and non-claim-related transactions. Such transactions may include the same ones as noted above for an estimated price. Host Blues using either an estimated price or an average price may, in accordance with Inter-Plan Programs policies, prospectively increase or reduce such prices to correct for over- or underestimation of past prices (i.e., prospective adjustments may mean that a current price reflects additional amounts or credits for claims already paid to providers or anticipated to be paid to or received from providers). However, the amount paid by the Member is a final price; no future price adjustment will result in increases or decreases to the ...
Inter-Plan Programs. (BLUECARD PROGRAM AND OTHERS) A small number of states require a Host Blue either (i) to use a basis for determining a member’s liability for covered health care services that does not reflect the entire savings realized, or expected to be realized, on a particular claim or (ii) to add a surcharge. Should the state in which health care services are accessed mandate liability calculation methods that differ from the negotiated price methodology or require a surcharge, Blue Shield would then calculate the member liability in accordance with applicable law. Under the BlueCard Program, recoveries from a Host Blue or its participating health care providers can arise in several ways, including, but not limited to, anti-fraud and abuse recoveries, health care provider/hospital audits, credit balance audits, utilization review refunds, and unsolicited refunds. In some cases, the Host Blue will engage a third party to assist in identification or collection of recovery amounts. Recovery amounts determined in these ways will be applied in accordance with applicable Inter-Plan Programs policies, which generally require correction on a claim-by-claim or prospective basis. When Covered Services, other than Emergency Services, are received from non-participating health care providers outside of California, Puerto Rico, and U.S. Virgin Islands, the amount(s) a member pays for such services will generally be based on either the Host Blue’s non-participating health care provider local payment or the pricing arrangements required by applicable state law. In these situations, the member may be responsible for the difference between the amount that the non- participating health care provider bills and the payment Blue Shield will make for the covered services as set forth in this paragraph. Claims for Covered Emergency Services are paid based on the Allowable Amount as defined in the Evidence of Coverage and Disclosure Form.
