Nonparticipating Providers Outside Our Service Area. 1. Member Liability Calculation When covered healthcare services are provided outside of our service area by nonparticipating providers, the amount(s) a member pays for such services will generally be based on either the Host Blue’s nonparticipating 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 nonparticipating provider bills and the payment we will make for the covered services as set forth in this paragraph. Payments for out-of-network emergency services are governed by applicable federal and state law.
Nonparticipating Providers Outside Our Service Area. Member Liability Calculation When Covered Services are provided outside of our service area by non-participating Providers, information regarding the amount you pay for such services is contained in the Covered Services section of this Booklet. Federal or state law, as applicable, will govern payments for out-of-Network emergency services. Blue Cross Blue Shield Global Core® If you are outside the United States, the Commonwealth of Puerto Rico, and the U.S. Virgin Islands (hereinafter “BlueCard service area”), you may be able to take advantage of Blue Cross Blue Shield Global Core when accessing Covered Services. Blue Cross Blue Shield Global Core is not served by a Host Blue. As such, when you receive care from providers outside the BlueCard service area, you will typically have to pay the providers and submit the claims yourself to obtain reimbursement for these services. If you need medical assistance services (including locating a doctor or hospital) outside the BlueCard service area, you should call the Blue Cross Blue Shield Global Core Service Center at 0.000.000.XXXX (2583) or call collect at 0.000.000.0000, 24 hours a day, and seven days a week. An assistance coordinator, working with a medical professional, can arrange a physician appointment or hospitalization, if necessary. • Inpatient Services In most cases, if you contact the Blue Cross Blue Shield Global Core Service Center for assistance, hospitals will not require you to pay for covered inpatient services, except for your cost-share amounts, deductibles, coinsurance, etc. In such cases, the hospital will submit your claims to the Blue Cross Blue Shield Global Core Service Center to begin claims processing. However, if you paid in full at the time of service, you must submit a claim to receive reimbursement for Covered Healthcare Services. You must contact Blue Cross and Blue Shield of South Carolina to obtain precertification for non-emergency inpatient services. • Outpatient Services Physicians, urgent care centers and other outpatient providers located outside the BlueCard service area will typically require you to pay in full at the time of service. You must submit a claim to obtain reimbursement for Covered Services. • Submitting a Blue Cross Blue Shield Global Core Claim When you pay for Covered Healthcare Services outside the BlueCard service area, you must submit a claim to obtain reimbursement. For institutional and professional claims, you should complete a Blue Cross Blue Shield ...
Nonparticipating Providers Outside Our Service Area. Member Liability Calculation. When Covered Services are provided outside of Our service area by nonparticipating Providers, the amount(s) a Member pays for such services will generally be based on either the Host Blue’s nonparticipating 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 nonparticipating Provider bills and the payment We will make for the Covered Services as set forth in this paragraph.
Nonparticipating Providers Outside Our Service Area. When covered healthcare services are provided outside of our service area by non-participating healthcare providers, information regarding the amount you pay for such services is contained in the Covered Services section of this policy.
