Liability Calculation Method Per Claim. Unless subject to a fixed dollar copayment, the calculation of Member liability on claims for Out-of-Area Covered Health Care Services processed through the BlueCard Program will be based on the lower of the provider’s billed charges or the negotiated price made available to Blue Shield by the Host Blue. Host Blues determine a negotiated price, which is reflected in the terms of each Host Blue’s health care provider contracts. The negotiated price made available to Blue Shield by the Host Blue may be represented by one of the following:
Liability Calculation Method Per Claim. The calculation of the Enrolled Member liability on claims for covered healthcare services processed through the BlueCard Program, if not a flat dollar copayment, will be based on the lower of the participating healthcare provider's billed covered charges or the negotiated price made available to BCBSRI by the Host Blue. Host Blues may use various methods to determine a negotiated price, depending on the terms of each Host Blue’s healthcare provider contracts. The negotiated price made available to BCBSRI by the Host Blue may represent a payment negotiated by a Host Blue with a healthcare provider that is one of the following:
(i) an actual price. An actual price is a negotiated payment without any other increases or decreases; or
(ii) 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
(iii) 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 healthcare 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 Enrolled Member is a final price; no future price adjustment will result in increases or decreases to the pricing of past claims. The BlueCard Program requires that the price submitted by a Host Blue to BCBSRI is a final price irrespective of any future adjustments based on the use of estimated or average pricing. A small number of states require a Host Blue either (i) to use a basis for determining Enrolled Member liability for covered healthcare services that does not reflect the entire savings r...
Liability Calculation Method Per Claim. The calculation of a Member's liability on claims for covered health care services incurred outside the geographic area BCBSM serves and processed through BlueCard will be based on the lower of the provider's billed charges or the negotiated price BCBSM pays the Host Plan. The methods employed 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 paid to a Host Plan by BCBSM on a claim for health care services processed through BlueCard may represent:
Liability Calculation Method Per Claim. The calculation of Member liability on claims for covered health care services processed through the Blue Card Program will be based on the lower of the participating Provider's billed covered charges or the negotiated price made available to BCBSNC by the Host Blue. The methods employed by a Host Blue to determine a negotiated price may vary among Host Blues based on the terms of each Host Blue’s Provider contracts. The negotiated price made available to BCBSNC by a Host Blue may represent a payment that is one of the following:
(i) an actual price. An actual price is a negotiated payment without any other increases or decreases (“Actual Price”), or
(ii) an estimated price. An estimated price is a negotiated payment increased or reduced 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 (“Estimated Price”), or
(iii) 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 Providers or a similar classification of its Providers and other claim- and non-claim-related transactions (“Average Price”). Such transactions may include the same ones as noted above for an estimated price. Host Blues using either the Estimated Price or Average Price may, in accordance with Inter-Plan Programs policies, 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; no future price adjustment will be applied to claims already paid. A small number of states may require a Host Blue to either (i) use a basis for determining Member liability for covered healthcare services that does not reflect the entire amount of realized or expected savings on a particular claim, or (ii) add a surcharge. Should any state enact a law that mandates liability calculation methods that differ from the negotiated price methodology or require a surcharge, BCBSNC would then calculate Member liability in accordance with applicable law.
Liability Calculation Method Per Claim. The calculation of the member copay, if not a flat dollar copay, for out-of-area covered healthcare services processed through the BlueCard Program will be based on the lower of the participating healthcare provider's billed covered charges or the negotiated price made available to Anthem by the Host Blue. Host Blues may use various methods to determine a negotiated price, depending on the terms of each Host Blue’s healthcare provider contracts. The negotiated price made available to Anthem by the Host Blue may represent a payment negotiated by a Host Blue with a healthcare provider that is one of the following:
Liability Calculation Method Per Claim. The calculation of the Member liability on claims for covered healthcare services processed through the BlueCard Program will be based on the lower of the participating healthcare provider's billed covered charges or the negotiated price made available to Highmark Delaware by the Host Blue. The calculation of Group's liability on claims for covered healthcare services processed through the BlueCard Program will be based on the negotiated price made available to Highmark Delaware by the Host Blue. Sometimes, this negotiated price may be greater than billed charges if the Host Blue has negotiated with its participating healthcare provider(s) an inclusive allowance (e.g., per case or per day amount) for specific healthcare services. Host Blues may use various methods to determine a negotiated price, depending on the terms of each Host Blue’s healthcare provider contracts. The negotiated price made available to Highmark Delaware by the Host Blue may represent a payment negotiated by a Host Blue with a healthcare provider that is one of the following:
Liability Calculation Method Per Claim. The calculation of Subscriber liability on claims for covered health care services incurred outside the geographic area Blue Shield of California serves, and processed through BlueCard will be based on the lower of the provider's billed charges or the negotiated price Blue Shield of California pays the Host Blue. The methods employed by a Host Blue to determine a negotiated price will vary among Host Blues based on the terms of each Host Blue’s provider contracts. The negotiated price paid to a Host Blue by Blue Shield of California on a claim for health care services processed through BlueCard may represent:
Liability Calculation Method Per Claim. The calculation of Participant liability on claims for covered health care services incurred outside the geographic area Blue Shield serves, and processed through BlueCard will be based on the negotiated price Blue Shield pays the Host Blue. The calculation of County liability on claims for covered health care services incurred outside the geographic area Blue Shield serves, and processed through BlueCard will be based on the negotiated price Blue Shield pays the Host Blue. The methods employed by a Host Blue to determine a negotiated price will vary among Host Blues based on the terms of each Host Blue’s provider contracts. The negotiated price paid to a Host Blue by Blue Shield on a claim for health care services processed through BlueCard may represent:
Liability Calculation Method Per Claim. Unless subject to a fixed dollar copayment, the calculation of the member liability on claims for covered healthcare services will be based on the lower of the participating provider's billed covered charges or the negotiated price made available to Blue Cross and Blue Shield of Alabama by the Host Blue. Host Blues determine a negotiated price, which is reflected in the terms of each Host Blue’s healthcare provider contracts. The negotiated price made available to Blue Cross and Blue Shield of Alabama by the Host Blue may be represented by one of the following:
Liability Calculation Method Per Claim. The calculation of Member liability on Claims for covered services processed through the BlueCard Program will be based on the lower of the provider’s billed charges or the negotiated price made available to Contractor by the Host Blue. The calculation of HCA liability on Claims for covered services processed through BlueCard will be based on the negotiated price made available to Contractor by the Host Blue. Sometimes, this negotiated price may be greater than billed charges if the Host Blue has negotiated with its participating healthcare provider(s) an inclusive allowance (e.g., per case or per day amount) for specific healthcare services.
