Common use of Reimbursement at Usual, Customary and Reasonable Level Clause in Contracts

Reimbursement at Usual, Customary and Reasonable Level. Upon ratification of this Agreement, the State and Union will require Blue Cross/Blue Shield to make concerted efforts to increase the number of participating providers in those areas in which the level of participation is less than 75%, by practice area. This may include providing additional incentives to providers. The parties acknowledge that additional discussion and review is necessary to determine how practice areas will be established for purposes of this Section. In addition, upon request Blue Cross/Blue Shield will provide letters to members for forwarding to their own doctors, requesting them to become participating providers. The letter is subject to the approval of the State and UAW. The State and Union will provide information to employees outlining the change in the reimbursement system. Educational material will include a streamlined system for identifying participating and non-participating providers to be distributed to employees on an annual basis. Beginning January 1, 1997, charges by a non-participating provider will be paid at the participating rate if 75% or more of that type of practitioners in the county are participating providers. The subscriber will be responsible for the remaining balance of the bill, and the amount paid will not count toward the deductible or out-of-pocket limit. For purposes of this Section, a practitioner's status as participating or non-participating will be established at the beginning of the Plan year and shall be considered unchanged throughout that year. Reimbursement for charges by a non-participating provider will be paid at the billed charge rate (subject to deductible and co-pay) if less than 75% of the practitioners of that type in that county are participating providers. This does not preclude Blue Cross/Blue Shield from negotiating directly with the provider for a lower fee on specific services. If an individual is under a course of treatment and the provider changes from participating to non-participating, charges will be paid regardless of the percentage of providers in the county, until the course of treatment has been completed. On a quarterly basis, Blue Cross/Blue Shield will provide information on reimbursements under this system to the Joint Committee which will expedite resolution of problems. Nothing will preclude the Committee from acting on the complaint of an individual prior to receipt of the report.

Reimbursement at Usual, Customary and Reasonable Level. Upon ratification of this Agreement, the State and Union will require Blue Cross/Blue Shield to make concerted efforts to increase the number of participating providers in those areas in which the level of participation is less than 75%, by practice area. This may include providing additional incentives to providers. The parties acknowledge that additional discussion and review is necessary to determine how practice areas will be established for purposes of this Section. In addition, upon request Blue Cross/Blue Shield will provide letters to members for forwarding to their own doctors, requesting them to become participating providers. The letter is subject to the approval of the State and UAW. The State and Union will provide information to employees outlining the change in the reimbursement system. Educational material will include a streamlined system for identifying participating and non-participating providers to be distributed to employees on an annual basis. Beginning January 1, 1997, charges by a non-participating provider will be paid at the participating rate if 75% or more of that type of practitioners in the county are participating providers. The subscriber will be responsible for the remaining balance of the billxxxx, and the amount paid will not count toward the deductible or out-of-pocket limit. For purposes of this Section, a practitioner's status as participating or non-participating will be established at the beginning of the Plan year and shall be considered unchanged throughout that year. Reimbursement for charges by a non-participating provider will be paid at the billed charge rate (subject to deductible and co-pay) if less than 75% of the practitioners of that type in that county are participating providers. This does not preclude Blue Cross/Blue Shield from negotiating directly with the provider for a lower fee on specific services. If an individual is under a course of treatment and the provider changes from participating to non-participating, charges will be paid regardless of the percentage of providers in the county, until the course of treatment has been completed. On a quarterly basis, Blue Cross/Blue Shield will provide information on reimbursements under this system to the Joint Committee which will expedite resolution of problems. Nothing will preclude the Committee from acting on the complaint of an individual prior to receipt of the report.