Common use of Liability Calculation Method Per Claim Clause in Contracts

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 realized, or expected to be realized, on a particular claim or (ii) to add a surcharge. Should the state in which healthcare services are accessed mandate liability calculation methods that differ from the negotiated price methodology or require a surcharge, BCBSRI would then calculate Enrolled Member liability in accordance with applicable law.

Liability Calculation Method Per Claim. The Unless subject to a fixed dollar copayment, 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 which is reflected in 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 be represented by a Host Blue with a healthcare provider that is one of the following: (i) an An actual price. An actual price is a negotiated rate of payment in effect at the time a claim is processed without any other increases or decreases; or (ii) an An estimated price. An estimated price is a negotiated rate of payment in effect at the time a claim is processed, 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- anti-fraud and abuse recoveries, provider refunds not applied on a claim-specific basis, retrospective settlements, settlements and performance-related bonuses or incentives; or (iii) an An average price. An average price is a percentage of billed covered charges in effect at the time a claim is processed 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 determine whether or not they will use an actual, estimated or average price. Host Blues using either an estimated price or an average price may, in accordance with Inter-Plan Programs policies, may prospectively increase or reduce such prices to correct for over- or underestimation of past prices (i.e., prospective adjustments adjustment may mean that a current price reflects additional amounts or credits for claims already paid to providers or anticipated to be paid to providers or refunds received or anticipated to be received from providers). However, the BlueCard Program requires that 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 method of claims payment by a Host Blue to Blues is taken into account by 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 in determining Enrolled Member liability for covered healthcare 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 healthcare services are accessed mandate liability calculation methods that differ from the negotiated price methodology or require a surcharge, BCBSRI would then calculate Enrolled Member liability in accordance with applicable lawyour premiums.

Liability Calculation Method Per Claim. The Unless subject to a fixed dollar copayment, 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 which is reflected in 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 be represented by a Host Blue with a healthcare provider that is one of the following: (i) an An actual price. An actual price is a negotiated rate of payment in effect at the time a claim is processed without any other increases or decreases; or (ii) an An estimated price. An estimated price is a negotiated rate of payment in effect at the time a claim is processed, 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- anti-fraud and abuse recoveries, provider refunds not applied on a claim-specific basis, retrospective settlements, settlements and performance-performance- related bonuses or incentives; or (iii) an An average price. An average price is a percentage of billed covered charges in effect at the time a claim is processed 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 determine whether or not they will use an actual, estimated or average price. Host Blues using either an estimated price or an average price may, in accordance with Inter-Plan Programs policies, may prospectively increase or reduce such prices to correct for over- or underestimation of past prices (i.e., prospective adjustments adjustment may mean that a current price reflects additional amounts or credits for claims already paid to providers or anticipated to be paid to providers or refunds received or anticipated to be received from providers). However, the BlueCard Program requires that 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 method of claims payment by a Host Blue to Blues is taken into account by 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 in determining Enrolled Member liability for covered healthcare 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 healthcare services are accessed mandate liability calculation methods that differ from the negotiated price methodology or require a surcharge, BCBSRI would then calculate Enrolled Member liability in accordance with applicable lawyour premiums.

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- claim and non-claim-claim- related transactions. Such transactions may include, but are not limited to, anti- fraud antifraud 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 realized, or expected to be realized, on a particular claim or (ii) to add a surcharge. Should the state in which healthcare services are accessed mandate liability calculation methods that differ from the negotiated price methodology or require a surcharge, BCBSRI would then calculate Enrolled Member liability in accordance with applicable law.

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 copaymentCopayment, will be based on the lower of of: the participating healthcare provider's ’s billed covered charges for covered services; or the negotiated price made available to BCBSRI the Plan by the Host Blue. Host Blues may use various methods to determine a negotiated price, depending on upon the terms of each Host Blue’s healthcare provider contracts. The negotiated price made available to BCBSRI the Plan 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) or • 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-claimnonclaim-related transactions. Such transactions may include, but are not limited to, anti- anti-fraud and abuse recoveries, provider refunds not applied on a claim-specific basis, retrospective settlements, and performance-related bonuses or incentives; or (iii) or • 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 the Plan 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) either: to use a basis for determining Enrolled Member liability for covered healthcare services that does not reflect the entire savings realized, or expected to be realized, on a particular claim claim; or (ii) to add a surcharge. Should the state in which healthcare services are accessed mandate liability calculation methods that differ from the negotiated price methodology or require a surcharge, BCBSRI the Plan would then calculate Enrolled Member liability in accordance with applicable law.