Out-of-Area Services Sample Clauses

Out-of-Area Services. Blue Cross and Blue Shield of Louisiana has a variety of relationships with other Blue Cross and/or Blue Shield Plans and their Licensed Controlled Affiliates (“Licensees”). Generally, these relationships are called “Inter-Plan Arrangements.” These Inter-Plan Arrangements work based on rules and procedures issued by the Blue Cross and Blue Shield Association. Whenever You obtain healthcare services outside the geographic area We serve, the Claim for those services may be processed through one of these Inter-Plan Arrangements. The Inter-Plan Arrangements are described below. When You receive care outside of Our service area, You will receive it from one of two kinds of Providers. Most Providers (“Participating Providers”) contract with the local Blue Cross and/or Blue Shield Licensee in that geographic area (“Host Blue”). Some Providers (“Non-Participating Providers”) do not contract with the Host Blue. We explain below how We pay both kinds of Providers. Inter-Plan Arrangements Eligibility – Claim Types All Claim types are eligible to be processed through Inter-Plan Arrangements, as described above, except for all Dental Care Benefits when paid as medical Benefits, and those Prescription Drug Benefits or vision care Benefits that may be administered by a third party contracted by Us to provide the specific service or services. 1. BlueCard® Program Under the BlueCard® Program, when You receive Covered Services within the geographic area served by a Host Blue, We will remain responsible for doing what We agreed to in the contract. However, the Host Blue is responsible for contracting with and generally handling all interactions with its Participating Providers. When You receive Covered Services outside Our service area and the Claim is processed through the BlueCard® Program, the amount You pay for the Covered Services is calculated based on the lower of: • the billed charges for Your Covered Services; or • the negotiated price that the Host Blue makes available to Us. Often, this “negotiated price” will be a simple discount that reflects an actual price that the Host Blue 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 settlements, incentive payments, and/or other credits or charges. Occasionally, it may be an average price, based on a discount that results in expected average savings for similar types of healthcare Pr...

Out-of-Area Services. 1. In areas where the Company offers contracting provider status directly or through arrangements to a class or classes of providers (such as Hospitals and/or physicians): a. When a provider in such class contracts with the Company, the provisions in Section A apply. b. When a provider in such class does not contract with the Company, the provisions in Section E apply. 2. For out-of-area arrangements other than those set forth in item F. 1: The Company has a variety of relationships with other Blue Cross and/or Blue Shield Licensees, referred to generally as "Inter-Plan Arrangements." These Inter-Plan Arrangements operate under rules and procedures issued by the Blue Cross Blue Shield Association ("Association"). Whenever Insureds access healthcare services outside the geographic area we serve, the claim for those services may be processed through one of these Inter-Plan Arrangements. The Inter-Plan Arrangements are described generally below. Typically, when accessing care outside the geographic area we serve, obtain care from healthcare providers that have a contractual agreement ("participating providers") with the local Blue Cross and/or Blue Shield Licensee in that other geographic area ("Host Blue"). In some instances, Insureds may obtain care from healthcare providers in the Host Blue geographic area that do not have a contractual agreement ("nonparticipating providers") with the Host Blue. We remain responsible for fulfilling our contractual obligations to you. Our payment practices in both instances are described below. a. BlueCard Program (not applicable to Ancillary Providers and Dental Services not associated with Accidental Injuries)

Out-of-Area Services. FHS shall manage and coordinate out-of-area services. PPG shall cooperate fully with FHS and shall provide any information necessary to transfer Members back into the Service Area, including but not limited to, notification to FHS of known or suspected out-of-area services. PPG shall accept the prompt transfer of Member to the care of PPG and its Participating Providers following the receipt of out-of-area services when medically appropriate.

Out-of-Area Services. Claim Administrator has a variety of relationships with other Blue Cross and/or Blue Shield licensees referred to generally as “Inter-Plan Arrangements.” These Inter-Plan Arrangements operate under rules and procedures issued by the Association. Whenever Covered Persons access health care services outside the geographic area Claim Administrator serves, the Claim for those services may be processed through one of these Inter-Plan Arrangements. The Inter-Plan Arrangements are described generally below. Claim Administrator’s services under this Agreement are governed by and subject to the Inter-Plan Arrangements rules in effect during the term of this Agreement, and a Host Blue is neither the agent nor the subcontractor of Claim Administrator. Typically, when accessing care outside the geographic area Claim Administrator serves, Covered Persons obtain care from Participating Healthcare Providers. In some instances, Covered Persons may obtain care from Non-Participating Healthcare Providers. Claim Administrator remains responsible for fulfilling its contractual obligations to Employer. Claim Administrator’s payment practices in both instances are described below. This disclosure describes how Claims are administered for Inter-Plan Arrangements and the fees that are charged in connection with the Inter-Plan Arrangements. Dental care benefits, when paid as stand-alone benefits, and prescription drug benefits or vision care benefits that may be administered by a third party contracted by Claim Administrator to provide the specific service or services, are not processed through Inter-Plan Arrangements.

Out-of-Area Services. Oscar covers only Emergency or Urgent Care services obtained outside of our Service area.

Out-of-Area Services. Out-of-area Emergency services are those services provided outside the Service Area of the Plan in conjunction with an Emergency. BSC-HMO shall assume costs associated with out-of-area Emergency services.

Out-of-Area Services. PacifiCare shall manage and coordinate Out-of-Area Services. Medical Group shall cooperate fully with PacifiCare in providing information that may be required for transferring Members back into the Medical Group Service Area, including promptly notifying PacifiCare of known or suspected Out-of-Area Services, and shall accept the prompt transfer of Members to the care of Medical Group and its Participating Providers following the receipt of Out-of-Area Services. PacifiCare, in conjuction with Medical Group and Hospital, shall make all decisions regarding the duration of a Member’s care at the Out-of-Area facility and transfer of the Member to a Medical Group Service Area facility.

Out-of-Area Services. The Company has a variety of relationships with other Blue Licensees referred to generally as “Inter-Plan Programs.” Whenever you obtain healthcare services outside of our service area, the Claims for these services may be processed through one of these Inter-Plan Programs, which include the BlueCard Program and may include negotiated National Account arrangements available between us and other Blue Licensees. Typically, when accessing care outside our service area, you will 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 Blue”). In some instances, you may obtain care from Non- Participating healthcare providers. Our payment practices in both instances are described below.

Out-of-Area Services. CareFirst has a variety of relationships with other Blue Cross and/or Blue Shield Licensees. Generally, these relationships are called “Inter-Plan Arrangements.” These Inter-Plan Arrangements work based on rules and procedures issued by the Blue Cross Blue Shield Association (“Association”). Whenever you access healthcare services outside the geographic area CareFirst serves, the claim for those services may be processed through one of these Inter-Plan Arrangements. The Inter-Plan Arrangements are described below. When you receive care outside of CareFirst service area, you will receive it from one of two kinds of providers. Most providers (“participating providers”) contract with the local Blue Cross and/or Blue Shield Plan in that geographic area (“Host Blue”). Some providers (“nonparticipating providers”) don’t contract with the Host Blue. CareFirst explains below how we pay both kinds of providers. All claim types are eligible to be processed through Inter-Plan Arrangements, as described above, except for all Dental Care Benefits except when paid as medical claims/benefits, and those Prescription Drug Benefits or Vision Care Benefits that may be administered by a third party contracted by CareFirst to provide the specific service or services.

Out-of-Area Services. The Plan has a variety of relationships with other Blue Cross and/or Blue Shield Licensees referred to generally as “Inter-Plan Programs.” Whenever Group Members and their enrolled dependents (collectively, “Members”) access healthcare services outside of the Plan’s Service Area, the claims for those services may be processed through one of these Inter-Plan Programs and presented to the Plan for payment according to the Inter-Plan Programs policies then in effect. The Inter-Plan Programs available to Members under this Agreement are described generally below. Typically, Members, when accessing care outside the Plan’s Service Area, will obtain care from healthcare providers that have a contractual agreement (i.e., are “Participating Providers” or “In-Network Providers”) with the local Blue Cross and/or Blue Shield Licensee in that other geographic area (“Host Blue”). In some instances, Members may obtain care from Non-Participating (or Out-of-Network) Providers. The Plan’s payment practices in both instances are described below. The Plan covers only limited healthcare services received by HMO Members outside the Plan’s Service Area. As used in this Amendment, then, any reference to covered healthcare services received within the geographic area serviced by a Host Plan and processed through the BlueCard® Program as described below means, with respect to HMO Members, services to treat an Emergency Condition that are obtained outside the Plan’s Service Area. Any other services obtained by HMO Members outside the Plan’s Service Area will not be covered, even when processed through any Inter-Plan Programs arrangements.