Common use of PLAN ALLOWANCE Clause in Contracts

PLAN ALLOWANCE. the amount used to determine payment by the Plan for Covered Services provided to a Member as set forth in SECTION SB - SCHEDULE OF BENEFITS of this Agreement, and to determine Member liability. Plan Allowance is based on the type of Provider who renders such Services or as required by law. In the case of a Network Provider, or Dentist, Telemedicine Provider, and Vision Provider, each of whom is a Network Provider, the Plan Allowance is the contractual allowance for Covered Services rendered by a Network Provider in a specific geographic region. A Network Provider, or Dentist, Telemedicine Provider or Vision Provider, each of whom is a Network Provider, will accept the Plan Allowance, plus any Member liability, as payment-in-full for Covered Services. In the case of an In-Area Out-of-Network Provider, the Plan Allowance shall be based on an adjusted contractual allowance for like services rendered by a Network Provider in the same geographic region. The Member will be responsible for any difference between the Provider’s billed charges and the Plan’s payment. In the case of an Out-of-Area Provider, whether or not such Out-of-Area Provider has an agreement with the local licensee of the Blue Cross Blue Shield Association, the Plan Allowance shall be determined, for other than pediatric dental and vision care and telemedicine Covered Services, based on prices received from the local licensee in accordance with the Plan’s participation in the INTER-PLAN ARRANGEMENTS as set forth in SECTION GP - GENERAL PROVISIONS of this Agreement. 112. PRECERTIFICATION (CERTIFICATION) - a process whereby the Medical Necessity and Appropriateness of Inpatient admissions, Services or place of Services is determined by the Plan prior to, or after, an admission or the performance of a procedure or Service.

PLAN ALLOWANCE. the amount used to determine payment by the Plan for Covered Services provided to a Member as set forth in SECTION SB - SCHEDULE OF BENEFITS of this Agreement, and to determine Member liability. Plan Allowance is based on the type of Provider who renders such Services Services, or as required by law. In the case of a Network Provider, Provider or Dentist, Telemedicine Provider, and Vision Provider, each of whom is a Network Provider, the Plan Allowance is the contractual allowance for Covered Services rendered by a Network Provider in a specific geographic region. A Network Provider, Provider or Dentist, Telemedicine Provider or Vision Provider, each of whom is a Network Provider, will accept the Plan Allowance, plus any Member liability, as payment-in-full for Covered Services. In the case of an In-Area Out-of-Network Provider, the Plan Allowance shall be based on an adjusted contractual allowance for like services rendered by a Network Provider in the same geographic region. The Member will be responsible for any difference between the Provider’s billed charges and the Plan’s payment. In the case of an Out-of-Area Provider, whether or not such Out-of-Area Provider has an agreement with the local licensee of the Blue Cross Blue Shield Association, the Plan Allowance shall be determined, for other than pediatric dental and vision care and telemedicine Covered Services, based on prices received from the local licensee in accordance with the Plan’s participation in the INTER-PLAN ARRANGEMENTS as set forth in SECTION GP - GENERAL PROVISIONS of this Agreement. 112. PRECERTIFICATION (CERTIFICATION) - a process whereby the Medical Necessity and Appropriateness of Inpatient admissions, Services or place of Services is determined by the Plan prior to, or after, an admission or the performance of a procedure or Service.

PLAN ALLOWANCE. the amount used to determine payment by the Plan for Covered Services provided to a Member as set forth in SECTION SB - SCHEDULE OF BENEFITS of this Agreement, and to determine Member liability. Plan Allowance is based on the type of Provider who renders such Services or as required by law. In the case of a Network Provider, or Dentist, Telemedicine Provider, and Vision Provider, each of whom is a Network Provider, the Plan Allowance is the contractual allowance for Covered Services rendered by a Network Provider in a specific geographic region. A Network Provider, or Dentist, Telemedicine Provider or Vision Provider, each of whom is a Network Provider, will accept the Plan Allowance, plus any Member liability, as payment-in-full for Covered Services. In the case of an In-Area Out-of-Network Provider, the Plan Allowance shall be based on an adjusted contractual allowance for like services rendered by a Network Provider in the same geographic region. The Member will be responsible for any difference between the Provider’s billed charges and the Plan’s payment. In the case of an Out-of-Area Provider, whether or not such Out-of-Area Provider has an agreement with the local licensee of the Blue Cross Blue Shield Association, the Plan Allowance shall be determined, for other than pediatric dental and vision care and telemedicine Covered Services, based on prices received from the local licensee in accordance with the Plan’s participation in the INTER-PLAN ARRANGEMENTS as set forth in SECTION GP - GENERAL PROVISIONS of this Agreement. 112110. PRECERTIFICATION (CERTIFICATION) - a process whereby the Medical Necessity and Appropriateness of Inpatient admissions, Services or place of Services is determined by the Plan prior to, or after, an admission or the performance of a procedure or Service.