Common use of Out-of-Network Benefits Clause in Contracts

Out-of-Network Benefits. The out-of-network benefits portion of this Contract provides coverage when You receive Covered Services from Non-Participating Providers. Your out-of-pocket expenses will be higher when You receive out-of-network benefits. In addition to Cost-Sharing, You will also be responsible for paying any difference between the Allowed Amount and the Non-Participating Provider’s charge. READ THIS ENTIRE CONTRACT CAREFULLY. IT IS YOUR RESPONSIBILITY TO UNDERSTAND THE TERMS AND CONDITIONS IN THIS CONTRACT. This Contract is governed by the laws of New York State. The insurance evidenced by this Contract provides DENTAL insurance ONLY. This Contract is a New York State of Health, The Official Health Plan Marketplace, certified stand-alone dental plan offered outside the New York State of Health. If You need foreign language assistance to understand this Contract, You may call Us at 0-000-000-0000 SECTION I Definitions Defined terms will appear capitalized throughout the Contract Acute: The onset of disease or injury, or a change in the Member's condition that would require prompt medical attention. Allowed Amount: The maximum amount on which Our payment is based for Covered Services. See the Cost-Sharing Expenses and Allowed Amount section of this Contract for a description of how the Allowed Amount is calculated. If Your Non-Participating Provider charges more than the Allowed Amount, You will have to pay the difference between the Allowed Amount and the Provider’s charge, in addition to any Cost-Sharing requirements. Appeal: A request for Us to review a Utilization Review decision or a Grievance again. Balance Billing: When a Non-Participating Provider bills You for the difference between the Non-Participating Provider’s charge and the Allowed Amount. A Participating Provider may not Balance Bill You for Covered Services. Contract: This Contract issued by BlueCross BlueShield of Western New York, including the Schedule of Benefits and any attached riders.

Out-of-Network Benefits. The out-of-network benefits portion of this Contract provides coverage when You receive Covered Services from Non-Participating Providers. Your out-of-pocket expenses will be higher when You receive out-of-network benefits. In addition to Cost-Sharing, You will also be responsible for paying any difference between the Allowed Amount and the Non-Participating Provider’s charge. READ THIS ENTIRE CONTRACT CAREFULLY. IT IS YOUR RESPONSIBILITY TO UNDERSTAND THE TERMS AND CONDITIONS IN THIS CONTRACT. This Contract is governed by the laws of New York State. The insurance evidenced by this Contract provides DENTAL insurance ONLY. This Contract is a New York State of Health, The Official Health Plan Marketplace, certified stand-alone dental plan offered outside the New York State of Health. If You need foreign language assistance to understand this Contract, You may call Us at 0-000-000-0000 SECTION I Definitions Defined terms will appear capitalized throughout the Contract Acute: The onset of disease or injury, or a change in the Member's condition that would require prompt medical attention. Allowed Amount: The maximum amount on which Our payment is based for Covered Services. See the Cost-Sharing Expenses and Allowed Amount section of this Contract for a description of how the Allowed Amount is calculated. If Your Non-Participating Provider charges more than the Allowed Amount, You will have to pay the difference between the Allowed Amount and the Provider’s charge, in addition to any Cost-Sharing requirements. Appeal: A request for Us to review a Utilization Review decision or a Grievance again. Balance Billing: When a Non-Participating Provider bills You for the difference between the Non-Participating Provider’s charge and the Allowed Amount. A Participating Provider may not Balance Bill You for Covered Services. Contract: This Contract issued by BlueCross BlueShield of Western Northeastern New York, including the Schedule of Benefits and any attached riders.