Common use of PROVIDER NETWORK STATUS Clause in Contracts

PROVIDER NETWORK STATUS. For Covered Services performed by an In-Network Provider, the allowed amount for this plan is the rate the Provider has agreedwith Alliant to accept as reimbursement for the Covered Services. Because In-Network Providers have agreed to accept the allowed amount as payment in full for that service, they should not send You a bill or collect for amounts above the allowed amount. However, You may receive a bill or be asked to pay all or a portion of the allowed amount to the extent You have not met Your Deductible or have a copayment or Coinsurance. Please call Customer Service at (000) 000-0000 for help in finding an In-Network Provider or visit XxxxxxxXxxxx.xxx. Providers who have not signed a contract with Us and are not in any of Our networks are Out-of-Network Providers. For certain Covered Services and depending on Your plan design, You may be required to pay a part of the MAC as Your cost share amount (e.g., Deductible, copayment, and/or Coinsurance). Please see the Summary of Benefits and Coverage for Your cost share responsibilities and limitations or call Customer Service at (000) 000-0000 to learn how Your plan’s benefits or cost share amounts may vary by the type of Provider You use. Alliant will not provide any reimbursement for non-Covered Services. You will be responsible for the total amount billed by Your Provider for Non-Covered Services. Both services specifically excluded by the terms of Your policy/plan and those received after benefits have been exhausted are Non-Covered Services. Benefits may be exhausted by exceeding, for example, calendar year day/visit limits. In some circumstances, such as where there is no In-Network Provider available for the Covered Service, We may authorize the in-network cost share amounts (Deductible, Copayment, and/or Coinsurance) to apply to a claim for a Covered Service You receive from an Out-of-Network Provider. In such circumstance, You must contact Us in advance of obtaining the Covered Service. We also may authorize the in-network cost share amounts to apply to a claim for Covered Services if You receive Emergency Services from an Out-of-Network Provider and are not able to contact Us until after the Covered Service is rendered. If We authorize a Covered Service so that You are responsible for the in-network cost share amounts, You may still beliable for the difference between the MAC and the Out-of-Network Provider’s charge. Please contact Customer Service at (000)000-0000 for Authorized Services information or to request authorization.

PROVIDER NETWORK STATUS. The allowed amount may vary depending upon whether the Provider is an In-Network or an Out-of-Network Provider. For Covered Services performed by an In-Network Provider, the allowed amount for this plan is the rate the Provider has agreedwith agreed with Alliant to accept as reimbursement for the Covered Services. Because In-Network Providers have agreed to accept the allowed amount as payment in full for that service, they should not send You you a bill or collect for amounts above the allowed amount. However, You you may receive a bill or be asked to pay all or a portion of the allowed amount to the extent You you have not met Your your Deductible or have a copayment or Coinsurance. Please call Customer Service customer service at (000) 000-0000 for help in finding an In-Network Provider or visit XxxxxxxXxxxx.xxx. Providers who have not signed a contract with Us us and are not in any of Our our networks are Out-of-Network Providers. For certain Covered Services and depending on Your you receive from Out-of-Network Providers (other than emergency services), the MAC for this plan design, You may will be required to pay a part one of the following as determined by Alliant: • An amount based on our out-of-network fee schedule/rate, which we have established at our discretion, and which we reserve the right to modify from time to time, after considering one or more of the following: reimbursement amounts accepted by like/similar providers contracted with Alliant, reimbursement amounts paid by the Centers for Medicare and Medicaid Services for the same services or supplies, and other industry cost, reimbursement and utilization data; or • An amount based on information provided by a third-party vendor, which may reflect one or more of the following factors: (1) the complexity or severity of treatment; (2) level of skill and experience required for the treatment; or (3) comparable providers’ fees and costs to deliver care; or • An amount negotiated by us or a third- party vendor which has been agreed to by the Provider. This may include rates for services coordinated through case management; or • An amount equal to the total charges billed by the Provider, but only if such charges are less than the MAC calculated by using one of the methods described above. The MAC for out-of-network Emergency Medical Services is calculated as Your cost share described in the Department of Labor Regulation 29 CFR 2590.715-2719A(b)(3)(i)(A), (B) & (C); with respect to emergency services we will calculate the MAC as: • The amount (e.g.negotiated with In-Network Providers for the emergency service furnished, Deductibleexcluding any in-network copayment or Coinsurance imposed; • The amount for the emergency services calculated using the same method as described above for out-of-network services, copaymentexcluding any in-network copayment or Coinsurance imposed; or • The amount that would be paid under Medicare for the emergency service, and/or Coinsurance)excluding any in-network copayment or Coinsurance imposed. Unlike In-Network Providers, Out-of-Network Providers may send you a bill and collect the amount of the Provider’s charge that exceeds our MAC. You are responsible for paying the difference between the MAC and the amount the Provider charges. This amount can be significant. Choosing an In-Network Provider will likely result in lower out-of-pocket costs to you. Please see the Summary of Benefits and Coverage for Your cost share responsibilities and limitations or call Customer Service customer service at (000) 000-0000 to learn how Your plan’s benefits or cost share amounts may vary by the type of Provider You use. Alliant will not provide any reimbursement for non-Covered Services. You will be responsible for the total amount billed by Your Provider for Non-Covered Services. Both services specifically excluded by the terms of Your policy/plan and those received after benefits have been exhausted are Non-Covered Services. Benefits may be exhausted by exceeding, for example, calendar year day/visit limits. In some circumstances, such as where there is no help in finding an In-Network Provider available for the Covered Service, We may authorize the in-network cost share amounts (Deductible, Copayment, and/or Coinsurance) to apply to a claim for a Covered Service You receive from an Out-of-Network Provider. In such circumstance, You must contact Us in advance of obtaining the Covered Service. We also may authorize the in-network cost share amounts to apply to a claim for Covered Services if You receive Emergency Services from an Out-of-Network Provider and are not able to contact Us until after the Covered Service is rendered. If We authorize a Covered Service so that You are responsible for the in-network cost share amounts, You may still beliable for the difference between the MAC and the Out-of-Network Provider’s charge. Please contact Customer Service or visit our website at (000)000-0000 for Authorized Services information or to request authorizationXxxxxxxXxxxx.xxx.

PROVIDER NETWORK STATUS. The allowed amount may vary depending upon whether the Provider is an In-Network or an Out-of-Network Provider. For Covered Services performed by an In-Network Provider, the allowed amount for this plan is the rate the Provider has agreedwith agreed with Alliant to accept as reimbursement for the Covered Services. Because In-Network Providers have agreed to accept the allowed amount as payment in full for that service, they should not send You you a bill or collect for amounts above the allowed amount. However, You you may receive a bill or be asked to pay all or a portion of the allowed amount to the extent You you have not met Your your Deductible or have a copayment Copayment or Coinsurance. Please call Customer Service at (000) 000-0000 for help in finding an In-Network Provider or visit XxxxxxxXxxxx.xxx. Providers who have not signed a contract with Us us and are not in any of Our our networks are Out-of-Network Providers. For certain Covered Services you choose to receive from Out-of-Network Providers (other than emergency services), the MAC for this plan will be one of the following as determined by Alliant: • An amount based on our out-of-network fee schedule/rate, which we have established at our discretion, and depending which we reserve the right to modify from time to time, after considering one or more of the following: reimbursement amounts accepted by like/similar providers contracted with Alliant, reimbursement amounts paid by the Centers for Medicare and Medicaid Services for the same services or supplies, and other industry cost, reimbursement and utilization data; or • An amount based on Your plan designinformation provided by a third-party vendor, You which may be reflect one or more of the following factors: (1) the complexity or severity of treatment; (2) level of skill and experience required for the treatment; or (3) comparable providers’ fees and costs to pay deliver care; or • An amount negotiated by us or a part third- party vendor which has been agreed to by the Provider. This may include rates for services coordinated through case management; or • An amount equal to the total charges billed by the Provider, but only if such charges are less than the MAC calculated by using one of the methods described above. The MAC for out-of-network emergency medical services is calculated as described in Title 33 of the Official Code of Georgia Annotated (OCGA) 33-20E-4; with respect to emergency services we will calculate the MAC as Your cost share the greater of: • The verifiable contracted amount (e.g., Deductiblepaid by all eligible insurers for the provision of the same or similar services as determined by the Georgia Department of Insurance. • The most recent verifiable amount agreed to by Alliant and the nonparticipating emergency medical provider for the provision of the same services during such time as such Provider was In-Network with Alliant. • Such higher amount as Alliant may deem appropriate given the complexity and circumstances of the services provided. The amount paid does not include any amount of coinsurance, copayment, and/or Coinsurance)or deductible you may owe. Out-of-Network Providers of emergency services may bill you for any coinsurance, copayment, or deductible you may owe according to the terms of your policy. In the event you receive a surprise bill for nonemergency medical services from an out-of-network provider, and you did NOT actively choose the out-of-network provider prior to receiving services, we calculate the MAC as described above. Alliant reserves the right to request documentation from the out-of-network provider to confirm whether you received services through no choice of your own. Choosing an In-Network Provider will likely result in lower out-of-pocket costs to you. Please see the Summary of Benefits and Coverage for Your cost share responsibilities and limitations or call Customer Service at (000) 000-0000 to learn how Your plan’s benefits or cost share amounts may vary by the type of Provider You use. Alliant will not provide any reimbursement for non-Covered Services. You will be responsible for the total amount billed by Your Provider for Non-Covered Services. Both services specifically excluded by the terms of Your policy/plan and those received after benefits have been exhausted are Non-Covered Services. Benefits may be exhausted by exceeding, for example, calendar year day/visit limits. In some circumstances, such as where there is no help in finding an In-Network Provider available for the Covered Service, We may authorize the in-network cost share amounts (Deductible, Copayment, and/or Coinsurance) to apply to a claim for a Covered Service You receive from an Out-of-Network Provider. In such circumstance, You must contact Us in advance of obtaining the Covered Service. We also may authorize the in-network cost share amounts to apply to a claim for Covered Services if You receive Emergency Services from an Out-of-Network Provider and are not able to contact Us until after the Covered Service is rendered. If We authorize a Covered Service so that You are responsible for the in-network cost share amounts, You may still beliable for the difference between the MAC and the Out-of-Network Provider’s charge. Please contact Customer Service or visit our website at (000)000-0000 for Authorized Services information or to request authorizationXxxxxxxXxxxx.xxx.

PROVIDER NETWORK STATUS. The allowed amount may vary depending upon whether the Provider is an In-Network or an Out-of-Network Provider. For Covered Services performed by an In-Network Provider, the allowed amount for this plan is the rate the Provider has agreedwith agreed with Alliant to accept as reimbursement for the Covered Services. Because In-Network Providers have agreed to accept the allowed amount as payment in full for that service, they should not send You you a bill xxxx or collect for amounts above the allowed amount. However, You you may receive a bill xxxx or be asked to pay all or a portion of the allowed amount to the extent You you have not met Your your Deductible or have a copayment Copayment or Coinsurance. Please call Customer Service at (000) 000-0000 for help in finding an In-Network Provider or visit XxxxxxxXxxxx.xxx. Providers who have not signed a contract with Us us and are not in any of Our our networks are Out-of-Network Providers. For certain Covered Services and depending on Your you receive from Out-of-Network Providers (other than emergency services), the MAC for this plan design, You may will be required to pay a part one of the following as determined by Alliant: • An amount based on our out-of-network fee schedule/rate, which we have established at our discretion, and which we reserve the right to modify from time to time, after considering one or more of the following: reimbursement amounts accepted by like/similar providers contracted with Alliant, reimbursement amounts paid by the Centers for Medicare and Medicaid Services for the same services or supplies, and other industry cost, reimbursement and utilization data; or • An amount based on information provided by a third-party vendor, which may reflect one or more of the following factors: (1) the complexity or severity of treatment; (2) level of skill and experience required for the treatment; or (3) comparable providers’ fees and costs to deliver care; or • An amount negotiated by us or a third- party vendor which has been agreed to by the Provider. This may include rates for services coordinated through case management; or • An amount equal to the total charges billed by the Provider, but only if such charges are less than the MAC calculated by using one of the methods described above. The MAC for out-of-network Emergency Medical Services is calculated as Your cost share described in the Department of Labor Regulation 29 CFR 2590.715-2719A(b)(3)(i)(A), (B) & (C); with respect to emergency services we will calculate the MAC as: • The amount (e.g.negotiated with In-Network Providers for the emergency service furnished, Deductibleexcluding any in-network Copayment or Coinsurance imposed; • The amount for the emergency services calculated using the same method as described above for out-of-network services, copaymentexcluding any in-network Copayment or Coinsurance imposed; or • The amount that would be paid under Medicare for the emergency service, and/or Coinsurance)excluding any in-network Copayment or Coinsurance imposed. Unlike In-Network Providers, Out-of-Network Providers may send you a xxxx and collect the amount of the Provider’s charge that exceeds our MAC. You are responsible for paying the difference between the MAC and the amount the Provider charges. This amount can be significant. Choosing an In-Network Provider will likely result in lower out-of-pocket costs to you. Please see the Summary of Benefits and Coverage for Your cost share responsibilities and limitations or call Customer Service at (000) 000-0000 to learn how Your plan’s benefits or cost share amounts may vary by the type of Provider You use. Alliant will not provide any reimbursement for non-Covered Services. You will be responsible for the total amount billed by Your Provider for Non-Covered Services. Both services specifically excluded by the terms of Your policy/plan and those received after benefits have been exhausted are Non-Covered Services. Benefits may be exhausted by exceeding, for example, calendar year day/visit limits. In some circumstances, such as where there is no help in finding an In-Network Provider available for the Covered Service, We may authorize the in-network cost share amounts (Deductible, Copayment, and/or Coinsurance) to apply to a claim for a Covered Service You receive from an Out-of-Network Provider. In such circumstance, You must contact Us in advance of obtaining the Covered Service. We also may authorize the in-network cost share amounts to apply to a claim for Covered Services if You receive Emergency Services from an Out-of-Network Provider and are not able to contact Us until after the Covered Service is rendered. If We authorize a Covered Service so that You are responsible for the in-network cost share amounts, You may still beliable for the difference between the MAC and the Out-of-Network Provider’s charge. Please contact Customer Service or visit our website at (000)000-0000 for Authorized Services information or to request authorizationXxxxxxxXxxxx.xxx.

PROVIDER NETWORK STATUS. The allowed amount may vary depending upon whether the Provider is an In-Network or an Out-of-Network Provider. For Covered Services performed by an In-Network Provider, the allowed amount for this plan is the rate the Provider has agreedwith agreed with Alliant to accept as reimbursement for the Covered Services. Because In-Network Providers have agreed to accept the allowed amount as payment in full for that service, they should not send You you a bill xxxx or collect for amounts above the allowed amount. However, You you may receive a bill xxxx or be asked to pay all or a portion of the allowed amount to the extent You you have not met Your your Deductible or have a copayment or Coinsurance. Please call Customer Service at (000) 000-0000 for help in finding an In-Network Provider or visit XxxxxxxXxxxx.xxx. Providers who have not signed a contract with Us us and are not in any of Our our networks are Out-of-Network Providers. For certain Covered Services you choose to receive from Out-of-Network Providers, the MAC for this plan will be one of the following as determined by Alliant: • An amount based on our out-of-network fee schedule/rate, which we have established at our discretion, and depending which we reserve the right to modify from time to time, after considering one or more of the following: reimbursement amounts accepted by like/similar providers contracted with Alliant, reimbursement amounts paid by the Centers for Medicare and Medicaid Services for the same services or supplies, and other industry cost, reimbursement and utilization data; or • An amount based on Your plan designinformation provided by a third-party vendor, You which may be reflect one or more of the following factors: (1) the complexity or severity of treatment; (2) level of skill and experience required for the treatment; or (3) comparable providers’ fees and costs to pay deliver care; or • An amount negotiated by us or a part third- party vendor which has been agreed to by the Provider. This may include rates for services coordinated through case management; or • An amount equal to the total charges billed by the Provider, but only if such charges are less than the MAC calculated by using one of the methods described above. The MAC for out-of-network emergency medical services is calculated as described in Title 33 of the Official Code of Georgia Annotated (OCGA) 33-20E-4; with respect to emergency services we will calculate the MAC as Your cost share the greater of: • The verifiable contracted amount (e.g., Deductiblepaid by all eligible insurers for the provision of the same or similar services as determined by the Georgia Department of Insurance. • The most recent verifiable amount agreed to by Alliant and the nonparticipating emergency medical provider for the provision of the same services during such time as such Provider was In-Network with Alliant. • Such higher amount as Alliant may deem appropriate given the complexity and circumstances of the services provided. The amount paid does not include any amount of coinsurance, copayment, and/or Coinsurance)or deductible you may owe. Out-of-Network Providers of emergency services may xxxx you for any coinsurance, copayment, or deductible you may owe according to the terms of your policy. In the event you receive a surprise xxxx for nonemergency medical services from an out-of-network provider, and you did NOT actively choose the out-of-network provider prior to receiving services, we calculate the MAC as described above. Alliant reserves the right to request documentation from the out-of-network provider to confirm whether you received services through no choice of your own. Choosing an In-Network Provider will likely result in lower out-of-pocket costs to you. Please see the Summary of Benefits and Coverage for Your cost share responsibilities and limitations or call Customer Service at (000) 000-0000 to learn how Your plan’s benefits or cost share amounts may vary by the type of Provider You use. Alliant will not provide any reimbursement for non-Covered Services. You will be responsible for the total amount billed by Your Provider for Non-Covered Services. Both services specifically excluded by the terms of Your policy/plan and those received after benefits have been exhausted are Non-Covered Services. Benefits may be exhausted by exceeding, for example, calendar year day/visit limits. In some circumstances, such as where there is no help in finding an In-Network Provider available for the Covered Service, We may authorize the in-network cost share amounts (Deductible, Copayment, and/or Coinsurance) to apply to a claim for a Covered Service You receive from an Out-of-Network Provider. In such circumstance, You must contact Us in advance of obtaining the Covered Service. We also may authorize the in-network cost share amounts to apply to a claim for Covered Services if You receive Emergency Services from an Out-of-Network Provider and are not able to contact Us until after the Covered Service is rendered. If We authorize a Covered Service so that You are responsible for the in-network cost share amounts, You may still beliable for the difference between the MAC and the Out-of-Network Provider’s charge. Please contact Customer Service or visit our website at (000)000-0000 for Authorized Services information or to request authorizationXxxxxxxXxxxx.xxx.

PROVIDER NETWORK STATUS. The allowed amount may vary depending upon whether the Provider is an In-Network or an Out-of-Network Provider. For Covered Services performed by an In-Network Provider, the allowed amount for this plan is the rate the Provider has agreedwith agreed with Alliant to accept as reimbursement for the Covered Services. Because In-Network Providers have agreed to accept the allowed amount as payment in full for that service, they should not send You you a bill or collect for amounts above the allowed amount. However, You you may receive a bill or be asked to pay all or a portion of the allowed amount to the extent You you have not met Your your Deductible or have a copayment Copayment or Coinsurance. Please call Customer Service customer service at (000) 000-0000 for help in finding an In-Network Provider or visit XxxxxxxXxxxx.xxx. Providers who have not signed a contract with Us us and are not in any of Our our networks are Out-of-Network Providers. For certain Covered Services and depending on Your you receive from Out-of-Network Providers (other than emergency services), the MAC for this plan design, You may will be required to pay a part one of the following as determined by Alliant: • An amount based on our out-of-network fee schedule/rate, which we have established at our discretion, and which we reserve the right to modify from time to time, after considering one or more of the following: reimbursement amounts accepted by like/similar providers contracted with Alliant, reimbursement amounts paid by the Centers for Medicare and Medicaid Services for the same services or supplies, and other industry cost, reimbursement and utilization data; or • An amount based on information provided by a third-party vendor, which may reflect one or more of the following factors: (1) the complexity or severity of treatment; (2) level of skill and experience required for the treatment; or (3) comparable providers’ fees and costs to deliver care; or • An amount negotiated by us or a third- party vendor which has been agreed to by the Provider. This may include rates for services coordinated through case management; or • An amount equal to the total charges billed by the Provider, but only if such charges are less than the MAC calculated by using one of the methods described above. The MAC for out-of-network Emergency Medical Services are calculated as Your described in the Department of Labor Regulation 29 CFR 2590.715-2719A(b)(3)(i)(A), (B) & (C); with respect to emergency services will calculate cost share sharing as: • The amount (e.g.negotiated with In-Network Providers for the emergency service furnished, Deductibleexcluding any in-network Copayment or Coinsurance imposed; • The amount for the emergency services calculated using the same method as described above for Out-Of- Network services, copaymentexcluding any in-network Copayment or Coinsurance imposed; or • The amount that would be paid under Medicare for the emergency service, and/or Coinsurance)excluding any In-Network Copayment or Coinsurance imposed. Unlike In-Network Providers, Out-of-Network Providers may send you a bill and collect for the amount of the Provider’s charge that exceeds our MAC. You are responsible for paying the difference between the MAC and the amount the Provider charges. This amount can be significant. Choosing an In-Network Provider will likely result in lower out-of-pocket costs to you. Please see the Summary of Benefits and Coverage for Your cost share responsibilities and limitations or call Customer Service customer service at (000) 000-0000 to learn how Your plan’s benefits or cost share amounts may vary by the type of Provider You use. Alliant will not provide any reimbursement for non-Covered Services. You will be responsible for the total amount billed by Your Provider for Non-Covered Services. Both services specifically excluded by the terms of Your policy/plan and those received after benefits have been exhausted are Non-Covered Services. Benefits may be exhausted by exceeding, for example, calendar year day/visit limits. In some circumstances, such as where there is no help in finding an In-Network Provider available for the Covered Service, We may authorize the in-network cost share amounts (Deductible, Copayment, and/or Coinsurance) to apply to a claim for a Covered Service You receive from an Out-of-Network Provider. In such circumstance, You must contact Us in advance of obtaining the Covered Service. We also may authorize the in-network cost share amounts to apply to a claim for Covered Services if You receive Emergency Services from an Out-of-Network Provider and are not able to contact Us until after the Covered Service is rendered. If We authorize a Covered Service so that You are responsible for the in-network cost share amounts, You may still beliable for the difference between the MAC and the Out-of-Network Provider’s charge. Please contact Customer Service or visit our website at (000)000-0000 for Authorized Services information or to request authorizationXxxxxxxXxxxx.xxx.

PROVIDER NETWORK STATUS. The allowed amount may vary depending upon whether the Provider is an In-Network or an Out-of-Network Provider. For Covered Services performed by an In-Network Provider, the allowed amount for this plan is the rate the Provider has agreedwith agreed with Alliant to accept as reimbursement for the Covered Services. Because In-Network Providers have agreed to accept the allowed amount as payment in full for that service, they should not send You a bill xxxx or collect for amounts above the allowed amount. However, You may receive a bill xxxx or be asked to pay all or a portion of the allowed amount to the extent You have not met Your Deductible or have a copayment or Coinsurance. Please call Customer Service at (000) 000-0000 for help in finding an In-Network Provider or visit XxxxxxxXxxxx.xxx. Providers who have not signed a contract with Us and are not in any of Our our networks are Out-of-Network Providers. For certain Covered Services You choose to receive from Out-of-Network Providers, the MAC for this plan will be one of the following as determined by Alliant: • An amount based on Our out-of-network fee schedule/rate, which We have established at Our discretion, and depending which We reserve the right to modify from time to time, after considering one or more of the following: reimbursement amounts accepted by like/similar providers contracted with Alliant, reimbursement amounts paid by the Centers for Medicare and Medicaid Services for the same services or supplies, and other industry cost, reimbursement and utilization data; or • An amount based on Your plan designinformation provided by a third-party vendor, You which may be reflect one or more of the following factors: (1) the complexity or severity of treatment; (2) level of skill and experience required for the treatment; or (3) comparable providers’ fees and costs to pay deliver care; or • An amount negotiated by Us or a part third- party vendor which has been agreed to by the Provider. This may includerates for services coordinated through case management; or • An amount equal to the total charges billed by the Provider, but only if such charges are less than the MAC calculated by using one of the methods described above. The MAC for out-of-network emergency medical services is calculated as described in Title 33 of the Official Code of Georgia Annotated (OCGA) 33-20E-4; with respect to emergency services We will calculate the MAC as Your cost share the greater of: • The verifiable contracted amount (e.g., Deductiblepaid by all eligible insurers for the provision of the same or similar services as determined by the Georgia Department of Insurance. • The most recent verifiable amount agreed to by Alliant and the nonparticipating emergency medical provider for the provision of the same services during such time as such Provider was In-Network with Alliant. • Such higher amount as Alliant may deem appropriate given the complexity and circumstances of the services provided. The amount paid does not include any amount of coinsurance, copayment, and/or Coinsurance)or deductible You may owe. Please see the Summary Out-of-Network Providers of Benefits and Coverage emergency services may xxxx You for Your cost share responsibilities and limitations any coinsurance, copayment, or call Customer Service at (000) 000-0000 deductible You may owe according to learn how Your plan’s benefits or cost share amounts may vary by the type of Provider You use. Alliant will not provide any reimbursement for non-Covered Services. You will be responsible for the total amount billed by Your Provider for Non-Covered Services. Both services specifically excluded by the terms of Your policy/plan and those received after benefits have been exhausted are Non-Covered Services. Benefits may be exhausted by exceeding, for example, calendar year day/visit limits. In some circumstancesthe event You receive a surprise xxxx for non emergency medical services from an out-of-network provider, such and You did NOT actively choose the out-of-network provider prior to receiving services, We calculate the MAC as where there is described above. Alliant reserves the right to request documentation from the out-of-network provider to confirm whether You received services through no choice of Your own. Choosing an In-Network Provider available for the Covered Service, We may authorize the in-network cost share amounts (Deductible, Copayment, and/or Coinsurance) to apply to a claim for a Covered Service You receive from an Outwill likely result in lower out-of-Network Provider. In such circumstance, You must contact Us in advance of obtaining the Covered Service. We also may authorize the in-network cost share amounts pocket costs to apply to a claim for Covered Services if You receive Emergency Services from an Out-of-Network Provider and are not able to contact Us until after the Covered Service is rendered. If We authorize a Covered Service so that You are responsible for the in-network cost share amounts, You may still beliable for the difference between the MAC and the Out-of-Network Provider’s chargeYou. Please contact call Customer Service at (000)000-0000 for Authorized Services information help in finding an In-Network Provider or to request authorizationvisit Our website at XxxxxxxXxxxx.xxx.

PROVIDER NETWORK STATUS. The Maximum Allowed Amount may vary depending upon whether the provider is a Prudent Buyer Plan Provider, a Non-Prudent Buyer Plan Provider or a Related Health Provider. Prudent Buyer Plan Providers and CME. For Covered Services covered services performed by an In-Network Provider, a Prudent Buyer Plan Provider or CME the allowed amount Maximum Allowed Amount for this plan is Plan will be the rate the Prudent Buyer Plan Provider or CME has agreedwith Alliant agreed with us to accept as reimbursement for the Covered Servicescovered services. Because In-Network Prudent Buyer Plan Providers have agreed to accept the allowed amount Maximum Allowed Amount as payment in full for that servicethose covered services, they should not send You you a bill or collect for amounts above the allowed amountMaximum Allowed Amount. However, You you may receive a bill or be asked to pay all or a portion of the allowed amount Maximum Allowed Amount to the extent You you have not met Your your Deductible or have a copayment or CoinsuranceCo-Payment. Please call Customer Service at (000) 000-0000 the customer service telephone number on your ID card for help in finding an In-Network a Prudent Buyer Plan Provider or visit XxxxxxxXxxxx.xxxxxx.xxxxxx.xxx/xx. Providers who have If you go to a Hospital which is a Prudent Buyer Plan Provider, you should not signed a contract with Us and assume all providers in that Hospital are not in any of Our networks are Out-of-Network also Prudent Buyer Plan Providers. For certain Covered Services and depending on Your plan designTo receive the greater benefits afforded when covered services are provided by a Prudent Buyer Plan Provider, You you should request that all your provider services (such as services by an anesthesiologist) be performed by Prudent Buyer Plan Providers whenever you enter a Hospital. If you are planning to have outpatient surgery, you should first find out if the facility where the surgery is to be performed is an Ambulatory Surgical Center. An Ambulatory Surgical Center is licensed as a separate facility even though it may be required to pay located on the same grounds as a part of Hospital (although this is not always the MAC as Your cost share amount (e.g., Deductible, copayment, and/or Coinsurancecase). Please see If the Summary of Benefits and Coverage for Your cost share responsibilities and limitations or call Customer Service at (000) 000-0000 to learn how Your plan’s benefits or cost share amounts may vary by center is licensed separately, you should find out if the type of facility is a Prudent Buyer Plan Provider You use. Alliant will not provide any reimbursement for non-Covered Services. You will be responsible for before undergoing the total amount billed by Your Provider for Non-Covered Services. Both services specifically excluded by the terms of Your policy/plan and those received after benefits have been exhausted are Non-Covered Services. Benefits may be exhausted by exceeding, for example, calendar year day/visit limits. In some circumstances, such as where there is no In-Network Provider available for the Covered Service, We may authorize the in-network cost share amounts (Deductible, Copayment, and/or Coinsurance) to apply to a claim for a Covered Service You receive from an Out-of-Network Provider. In such circumstance, You must contact Us in advance of obtaining the Covered Service. We also may authorize the in-network cost share amounts to apply to a claim for Covered Services if You receive Emergency Services from an Out-of-Network Provider and are not able to contact Us until after the Covered Service is rendered. If We authorize a Covered Service so that You are responsible for the in-network cost share amounts, You may still beliable for the difference between the MAC and the Out-of-Network Provider’s charge. Please contact Customer Service at (000)000-0000 for Authorized Services information or to request authorizationsurgery.