Common use of PROVIDER NETWORK STATUS Clause in Contracts

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 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 xxxx or collect for amounts above the allowed amount. However, You may receive a 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 networks are Out-of-Network Providers. For 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 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 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 the greater of: • The verifiable contracted amount paid 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, 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 non emergency 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 call Customer Service at (000)000-0000 for help in finding an In-Network Provider or visit Our website at XxxxxxxXxxxx.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 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 xxxx bill or collect for amounts above the allowed amount. However, You you may receive a xxxx 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 networks are Out-of-Network Providers. For Covered Services You choose to you receive from Out-of-Network ProvidersProviders (other than emergency services), the MAC for this plan will be one of the following as determined by Alliant: • An amount based on Our our out-of-network fee schedule/rate, which We we have established at Our our discretion, and which We 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 us or a third- party vendor which has been agreed to by the Provider. This may includerates 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 Emergency Medical Services are calculated as described in Title 33 the Department of the Official Code of Georgia Annotated Labor Regulation 29 CFR 2590.715-2719A(b)(3)(i)(A), (OCGAB) 33-20E-4& (C); with respect to emergency services We will calculate the MAC as the greater ofcost sharing as: • The verifiable contracted amount paid 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 negotiated with In-Network with Alliant. Providers for the emergency service furnished, excluding any in-network Copayment or Coinsurance imposed; • Such higher amount as Alliant may deem appropriate given the complexity and circumstances of the services provided. The amount for the emergency services calculated using the same method as described above for Out-Of- Network services, excluding any in-network Copayment or Coinsurance imposed; or • The amount that would be paid does not include under Medicare for the emergency service, excluding any amount of coinsuranceIn-Network Copayment or Coinsurance imposed. Unlike In-Network Providers, copayment, or deductible You may owe. Out-of-Network Providers may send you a bill and collect for the amount of emergency services may xxxx the Provider’s charge that exceeds our MAC. You are responsible for any coinsurance, copayment, or deductible You may owe according to paying the terms of Your policy. In the event You receive a surprise xxxx for non emergency 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 difference between the MAC as described aboveand the amount the Provider charges. Alliant reserves the right to request documentation from the out-of-network provider to confirm whether You received services through no choice of Your ownThis amount can be significant. Choosing an In-Network Provider will likely result in lower out-of-pocket costs to Youyou. Please call Customer Service customer service at (000)000000) 000-0000 for help in finding an In-Network Provider or visit Our our website at XxxxxxxXxxxx.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 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 xxxx or collect for amounts above the allowed amount. However, You you may receive a 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 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 networks are Out-of-Network Providers. For Covered Services You choose to you receive from Out-of-Network ProvidersProviders (other than emergency services), the MAC for this plan will be one of the following as determined by Alliant: • An amount based on Our our out-of-network fee schedule/rate, which We we have established at Our our discretion, and which We 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 us or a third- party vendor which has been agreed to by the Provider. This may includerates 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 Emergency Medical Services is calculated as described in Title 33 the Department of the Official Code of Georgia Annotated Labor Regulation 29 CFR 2590.715-2719A(b)(3)(i)(A), (OCGAB) 33-20E-4& (C); with respect to emergency services We we will calculate the MAC as the greater ofas: • The verifiable contracted amount paid 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 negotiated with In-Network with Alliant. Providers for the emergency service furnished, excluding any in-network copayment or Coinsurance imposed; • Such higher amount as Alliant may deem appropriate given the complexity and circumstances of the services provided. The amount for the emergency services calculated using the same method as described above for out-of-network services, excluding any in-network copayment or Coinsurance imposed; or • The amount that would be paid does not include under Medicare for the emergency service, excluding any amount of coinsurancein-network copayment or Coinsurance imposed. Unlike In-Network Providers, copayment, or deductible You may owe. Out-of-Network Providers may send you a xxxx and collect the amount of emergency services may xxxx the Provider’s charge that exceeds our MAC. You are responsible for any coinsurance, copayment, or deductible You may owe according to paying the terms of Your policy. In the event You receive a surprise xxxx for non emergency 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 difference between the MAC as described aboveand the amount the Provider charges. Alliant reserves the right to request documentation from the out-of-network provider to confirm whether You received services through no choice of Your ownThis amount can be significant. Choosing an In-Network Provider will likely result in lower out-of-pocket costs to Youyou. Please call Customer Service customer service at (000)000000) 000-0000 for help in finding an In-Network Provider or visit Our our website at XxxxxxxXxxxx.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 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 xxxx or collect for amounts above the allowed amount. However, You you may receive a 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 networks are Out-of-Network Providers. For Covered Services You choose to you receive from Out-of-Network ProvidersProviders (other than emergency services), the MAC for this plan will be one of the following as determined by Alliant: • An amount based on Our our out-of-network fee schedule/rate, which We we have established at Our our discretion, and which We 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 us or a third- party vendor which has been agreed to by the Provider. This may includerates 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 Emergency Medical Services is calculated as described in Title 33 the Department of the Official Code of Georgia Annotated Labor Regulation 29 CFR 2590.715-2719A(b)(3)(i)(A), (OCGAB) 33-20E-4& (C); with respect to emergency services We we will calculate the MAC as the greater ofas: • The verifiable contracted amount paid 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 negotiated with In-Network with Alliant. Providers for the emergency service furnished, excluding any in-network Copayment or Coinsurance imposed; • Such higher amount as Alliant may deem appropriate given the complexity and circumstances of the services provided. The amount for the emergency services calculated using the same method as described above for out-of-network services, excluding any in-network Copayment or Coinsurance imposed; or • The amount that would be paid does not include under Medicare for the emergency service, excluding any amount of coinsurancein-network Copayment or Coinsurance imposed. Unlike In-Network Providers, copayment, or deductible You may owe. Out-of-Network Providers may send you a xxxx and collect the amount of emergency services may xxxx the Provider’s charge that exceeds our MAC. You are responsible for any coinsurance, copayment, or deductible You may owe according to paying the terms of Your policy. In the event You receive a surprise xxxx for non emergency 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 difference between the MAC as described aboveand the amount the Provider charges. Alliant reserves the right to request documentation from the out-of-network provider to confirm whether You received services through no choice of Your ownThis amount can be significant. Choosing an In-Network Provider will likely result in lower out-of-pocket costs to Youyou. Please call Customer Service at (000)000000) 000-0000 for help in finding an In-Network Provider or visit Our our website at XxxxxxxXxxxx.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 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 xxxx bill or collect for amounts above the allowed amount. However, You you may receive a xxxx 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 networks are Out-of-Network Providers. For Covered Services You you choose to receive from Out-of-Network ProvidersProviders (other than emergency services), the MAC for this plan will be one of the following as determined by Alliant: • An amount based on Our our out-of-network fee schedule/rate, which We we have established at Our our discretion, and which We 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 us or a third- party vendor which has been agreed to by the Provider. This may includerates 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 we will calculate the MAC as the greater of: • The verifiable contracted amount paid 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, or deductible You you may owe. Out-of-Network Providers of emergency services may xxxx You bill you for any coinsurance, copayment, or deductible You you may owe according to the terms of Your your policy. In the event You you receive a surprise xxxx bill for non emergency nonemergency medical services from an out-of-network provider, and You you did NOT actively choose the out-of-network provider prior to receiving services, We we calculate the MAC as described above. Alliant reserves the right to request documentation from the out-of-network provider to confirm whether You you received services through no choice of Your your own. Choosing an In-Network Provider will likely result in lower out-of-pocket costs to Youyou. Please call Customer Service at (000)000000) 000-0000 for help in finding an In-Network Provider or visit Our our website at XxxxxxxXxxxx.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 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 xxxx bill or collect for amounts above the allowed amount. However, You you may receive a xxxx 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 networks are Out-of-Network Providers. For Covered Services You choose to you receive from Out-of-Network ProvidersProviders (other than emergency services), the MAC for this plan will be one of the following as determined by Alliant: • An amount based on Our our out-of-network fee schedule/rate, which We we have established at Our our discretion, and which We 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 us or a third- party vendor which has been agreed to by the Provider. This may includerates 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 Emergency Medical Services is calculated as described in Title 33 the Department of the Official Code of Georgia Annotated Labor Regulation 29 CFR 2590.715-2719A(b)(3)(i)(A), (OCGAB) 33-20E-4& (C); with respect to emergency services We we will calculate the MAC as the greater ofas: • The verifiable contracted amount paid 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 negotiated with In-Network with Alliant. Providers for the emergency service furnished, excluding any in-network copayment or Coinsurance imposed; • Such higher amount as Alliant may deem appropriate given the complexity and circumstances of the services provided. The amount for the emergency services calculated using the same method as described above for out-of-network services, excluding any in-network copayment or Coinsurance imposed; or • The amount that would be paid does not include under Medicare for the emergency service, excluding any amount of coinsurancein-network copayment or Coinsurance imposed. Unlike In-Network Providers, copayment, or deductible You may owe. Out-of-Network Providers may send you a bill and collect the amount of emergency services may xxxx the Provider’s charge that exceeds our MAC. You are responsible for any coinsurance, copayment, or deductible You may owe according to paying the terms of Your policy. In the event You receive a surprise xxxx for non emergency 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 difference between the MAC as described aboveand the amount the Provider charges. Alliant reserves the right to request documentation from the out-of-network provider to confirm whether You received services through no choice of Your ownThis amount can be significant. Choosing an In-Network Provider will likely result in lower out-of-pocket costs to Youyou. Please call Customer Service customer service at (000)000000) 000-0000 for help in finding an In-Network Provider or visit Our our website at XxxxxxxXxxxx.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 agreed with 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 xxxx bill or collect for amounts above the allowed amount. However, You may receive a xxxx 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 Certificate of Coverage – Individual/Family Plans (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. MEMBER COST SHARE For certain Covered Services and depending on Your plan design, You choose 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. Authorized Services 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 ProvidersProvider. In such circumstance, You must contact Us in advance of obtaining the MAC for this plan will be one of Covered Service. We also may authorize the following as determined by Alliant: • An amount based on Our out-ofin-network fee schedule/rate, which We have established at Our discretion, and which We reserve the right cost share amounts to modify apply to a claim for Covered Services if You receive Emergency Services 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 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 the greater of: • The verifiable contracted amount paid 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, or deductible You may owe. an Out-of-Network Providers of emergency services may xxxx 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 any coinsurancethe in-network cost share amounts, copayment, or deductible You may owe according to still beliable for the terms of Your policy. In difference between the event You receive a surprise xxxx for non emergency medical services from an outMAC and the 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 YouProvider’s charge. Please call contact Customer Service at (000)000-0000 for help in finding an In-Network Provider Authorized Services information or visit Our website at XxxxxxxXxxxx.xxxto 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 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 xxxx or collect for amounts above the allowed amount. However, You you may receive a 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 networks are Out-of-Network Providers. For Covered Services You 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 our out-of-network fee schedule/rate, which We we have established at Our our discretion, and which We 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 us or a third- party vendor which has been agreed to by the Provider. This may includerates 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 we will calculate the MAC as the greater of: • The verifiable contracted amount paid 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, or deductible You you may owe. Out-of-Network Providers of emergency services may xxxx You you for any coinsurance, copayment, or deductible You you may owe according to the terms of Your your policy. In the event You you receive a surprise xxxx for non emergency nonemergency medical services from an out-of-network provider, and You you did NOT actively choose the out-of-network provider prior to receiving services, We we calculate the MAC as described above. Alliant reserves the right to request documentation from the out-of-network provider to confirm whether You you received services through no choice of Your your own. Choosing an In-Network Provider will likely result in lower out-of-pocket costs to Youyou. Please call Customer Service at (000)000000) 000-0000 for help in finding an In-Network Provider or visit Our our website at XxxxxxxXxxxx.xxx.