Common use of Non-Contracting Providers Clause in Contracts

Non-Contracting Providers. If You receive services from a provider who has not contracted with the Company or another Blue Cross and Blue Shield Company (for services provided outside the Company Service Area), the allowable charges (before application of any Deductible, Coinsurance, Copayment, shared payment or benefit limits called for by this Contract) will be determined as follows and You are responsible for any difference between the allowable charge and the actual charge. As used in this section, "Contracting" means contracting with the Company. When a covered service that is required for a Medical Emergency is provided by a Non-Contracting Provider, the allowable charge will be the actual charge for the service up to the maximum amount allowable for the same service provided by providers that are Contracting Institutional Providers of the Company that are the same kinds of providers or Contracting Professional Providers of the Company with the same licensure or certification. "Same service" as used in this Section E shall be determined on the basis of the intended result of the service and not the technical methodology used by the provider to perform that service. All reimbursement identified in this Section E is paid according to the cost-containment policies and procedures applicable to Contracting Providers. If You receive services from a Non-Contracting Provider, You will be responsible for payment for services for which payment is not made by the Company due to a cost-containment policy or procedure applicable to a Contracting Provider of the same licensure providing the same service. Such cost-containment policies include, but are not limited to, determinations by the Company that the services provided are of such a nature that they should be considered one service with a single payment, or that the billing for service inappropriately categorized the nature of the services performed, in the opinion of the Company, and payments should be made for a different type or different intensity of service.