Value-Based Programs. If you receive covered healthcare services under a Value-Based Program inside a Host Blue’s service area, you will not be responsible for paying any of the Provider Incentives, risk-sharing, and/or Care Coordinator Fees that are a part of such an arrangement, except when a Host Blue passes these fees to us through average pricing or fee schedule adjustments. The following defined terms only apply to the BlueCard section only: • Care Coordinator Fee is a fixed amount paid by us to providers periodically for Care Coordination under a Value-Based Program. • Care Coordination is organized, information-driven patient care activities intended to facilitate the appropriate responses to an enrolled member’s healthcare needs across the continuum of care. • Value-Based Program (VBP) is an outcomes-based payment arrangement and/or a coordinated care model facilitated with one or more local providers that is evaluated against cost and quality metrics/factors and is reflected in provider payment. • Provider Incentive is an additional amount of compensation paid to a healthcare provider by us, based on the provider’s compliance with agreed-upon procedural and/or outcome measures for a particular group of covered persons. Inter-Plan Programs: Federal/State Taxes/Surcharges/Fees Federal or state laws or regulations may require a surcharge, tax or other fee that applies to insured accounts. If applicable, we will include any such surcharge, tax or other fee as part of the claim charge passed on to you. Nonparticipating Providers Outside Our Service Area • Enrolled Member Liability Calculation When covered healthcare services are provided outside of BCBSRI service area by nonparticipating providers, the amount an enrolled member pays for such services will generally be based on either the Host Blue’s nonparticipating provider local payment or the pricing arrangements required by applicable law. In these situations, the enrolled member may be responsible for the difference between the amount that the nonparticipating provider bills and the payment BCBSRI will make for the covered services as set forth in this paragraph. Federal or state law, as applicable, will govern payments, including but not limited to, emergency services, air ambulance services, and certain covered healthcare services rendered by a nonparticipating provider. • Exceptions In some exception cases, BCBSRI may pay claims from nonparticipating healthcare providers outside of BCBSRI service area based on the ...
Value-Based Programs. If you receive covered healthcare services under a Value-Based Program inside a Host Blue’s service area, you will not be responsible for paying any of the Provider Incentives, risk-sharing, and/or Care Coordinator Fees that are a part of such an arrangement, except when a Host Blue passes these fees to us through average pricing or fee schedule adjustments. The following defined terms only apply to the BlueCard section only: • Care Coordinator Fee is a fixed amount paid by us to providers periodically for Care Coordination under a Value-Based Program. • Care Coordination is organized, information-driven patient care activities intended to facilitate the appropriate responses to an enrolled member’s healthcare needs across the continuum of care. • Value-Based Program (VBP) is an outcomes-based payment arrangement and/or a coordinated care model facilitated with one or more local providers that is evaluated against cost and quality metrics/factors and is reflected in provider payment. • Provider Incentive is an additional amount of compensation paid to a healthcare provider by us, based on the provider’s compliance with agreed-upon procedural and/or outcome measures for a particular group of covered persons. Inter-Plan Programs: Federal/State Taxes/Surcharges/Fees Federal or state laws or regulations may require a surcharge, tax or other fee that applies to insured accounts. If applicable, we will include any such surcharge, tax or other fee as part of the claim charge passed on to you. Nonparticipating Providers Outside Our Service Area How we pay nonparticipating providers outside our service area is explained in How Non-network Providers Are Paid section above.
Value-Based Programs. A “Value-Based Program” is an outcomes-based payment arrangement and/or a coordinated care model facilitated with one or more local providers that is evaluated against cost and quality metrics/factors and is reflected in provider payment. Wellmark or Host Blues may enter into collaborative arrangements with Value- Based Programs under which the health care organizations participating in such programs are eligible for financial incentives relating to quality and cost-effective care of Wellmark members. Identifiable Data regarding Account's Members may be included in information Wellmark or Host Blues provide to Value-Based Programs and used by the Value-Based Program and its providers.
Value-Based Programs a. Members may access covered services from providers that participate in a Host Blue’s and/or Contractor’s Value-Based Programs. A Host Blue’s Value-Based Program may
Value-Based Programs. Blue Shield Value-Based Programs Enrollees may access covered services from providers that participate in a Blue Shield Value-Based Program. Blue Shield Value-Based Programs include, but are not limited to, Accountable Care Organizations, Episode Based Payments, Patient Centered Medical Homes and Shared Savings arrangements. Blue Shield has included any associated costs in the Premium for Blue Shield Value-Based Programs when applicable under this agreement. BlueCard® Program Blue Shield has included a factor for bulk distributions from Host Blues in the premium for Value-Based Programs when applicable under this agreement. Non-Participating Providers Outside of California When Covered Services, other than Emergency Services, are received from non-participating providers outside of California, but within the BlueCard Service Area, the amount(s) a Member pays for such services will generally be based on the Host Blue’s non-participating provider local payment, the Allowable Amount Blue Shield pays a Non-Participating provider in California if the Host Blue has no non-participating provider allowance, or the pricing arrangements required by applicable state law. In these situations, the Member may be responsible for the difference between the amount that the non-participating provider bills and the payment Blue Shield will make for the Covered Services as set forth in this paragraph. Claims for covered Emergency Services are paid based on the Allowable Amount as defined in the EOC. Blue Shield Global Core If Members are outside the BlueCard Service Area, they may be able to take advantage of Blue Shield Global Core when accessing Out-of-Area Covered Health Care Services. Blue Shield Global Core is unlike the BlueCard Program available in the BlueCard Service Area. Although Blue Shield Global Core assists Members with accessing a network of inpatient, outpatient, and professional providers, the network is not served by a Host Blue plan. As such, when Members receive care from providers outside the BlueCard Service Area, Members will typically have to pay the providers and submit the claims themselves to obtain reimbursement for these services. Details for Blue Shield Global Core claim submission are provided in the Inter-Plan Arrangements section of the EOC.
Value-Based Programs. BlueCard Program We have included a factor for bulk distributions from Host Blues in Your premium for Value-Based Programs when applicable under this contract.
Value-Based Programs. BlueCard® Program If you receive Covered Services under a Value- Based Program inside a Host Blue’s service area, you will not be responsible for paying any of the Provider Incentives, risk-sharing, and/or Care Co- ordinator Fees that are a part of such an arrange- ment, except when a Host Blue passes these fees to Blue Shield through average pricing or fee schedule adjustments. Negotiated (non–BlueCard Program) Arrange- ments If Blue Shield has entered into a Negotiated Ar- rangement with a Host Blue to provide Value- Based Programs to the Employer on your behalf, Blue Shield will follow the same procedures for Value-Based Programs administration and Care Coordinator Fees as noted above for the BlueCard Program. Claims for Emergency and Out-of-Area Urgent Services Emergency If Emergency Services were received and ex- penses were incurred by the Member for services other than medical transportation, the Member must submit a complete claim with the Emer- gency Service record for payment to the Plan, within one year after the first provision of Emer- gency Services for which payment is requested. If the claim is not submitted within this period, the Plan will not pay for those Emergency Services, unless the claim was submitted as soon as reason- ably possible as determined by the Plan. If the services are not preauthorized, the Plan will re- view the claim retrospectively for coverage. If the Plan determines that the services received were for a medical condition for which a reasonable person would not reasonably believe that an emergency condition existed and would not oth- erwise have been authorized, and, therefore, are not covered, it will notify the Member of that de- termination. The Plan will notify the Member of its determination within 30 days from receipt of the claim. In the event covered medical trans- portation services are obtained in such an emer- gency situation, the Blue Shield Access+ HMO shall pay the medical transportation provider di- rectly.
Value-Based Programs. BlueCard® Program If you receive Covered Services under a Value- Based Program inside a Host Blue’s service area, you will not be responsible for paying any of the Provider Incentives, risk-sharing, and/or Care Co- ordinator Fees that are a part of such an arrange- ment, except when a Host Blue passes these fees to Blue Shield through average pricing or fee schedule adjustments. Negotiated (non–BlueCard Program) Arrange- ments If Blue Shield has entered into a Negotiated Ar- rangement with a Host Blue to provide Value- Based Programs to the Employer on your behalf, Blue Shield will follow the same procedures for Value-Based Programs administration and Care Coordinator Fees as noted above for the BlueCard Program. Utilization Management State law requires that Health Plans disclose to Members and Health Plan providers the process used to authorize or deny health care services un- der the Plan. Blue Shield has completed documen- tation of this process as required under Section 1363.5 of the California Health and Safety Code. The document describing Blue Shield’s Utilization Management Program is available online at xxx.xxxxxxxxxxxx.xxx or Members may call the Customer Service Department at the number pro- vided on the back page of this EOC to request a copy.
Value-Based Programs. BlueCard® Program If you receive covered health care services under a Value-Based Program inside a Host Blue’s service area, you will not be responsible for paying any of the Provider Incentives, risk-sharing, and/or Care Coordinator Fees that are a part of such an arrangement, except when a Host Blue passes these fees to us through average pricing or fee schedule adjustments. The following defined terms only apply to Section 5.3: • Care Coordinator Fee is a fixed amount paid by us to providers periodically for Care Coordination under a Value-Based Program. • Care Coordination is organized, information-driven patient care activities intended to facilitate the appropriate responses to an enrolled member's healthcare needs across the continuum of care. • Value-Based Program (VBP) is an outcomes-based payment arrangement and/or a coordinated care model facilitated with one or more local providers that is evaluated against cost and quality metrics/factors and is reflected in provider payment. • Provider Incentive is an additional amount of compensation paid to a healthcare provider by us, based on the provider's compliance with agreed-upon procedural and/or outcome measures for a particular group of covered persons. Nonparticipating Providers Outside Our Service Area
Value-Based Programs. If you receive covered healthcare services under a Value-Based Program inside a Host Blue’s service area, you will not be responsible for paying any of the Provider Incentives, risk-sharing, and/or Care Coordinator Fees that are a part of such an arrangement, except when a Host Blue passes these fees to us through average pricing or fee schedule adjustments. The following defined terms only apply to the BlueCard section only: • Care Coordinator Fee is a fixed amount paid by us to providers periodically for Care Coordination under a Value-Based Program. • Care Coordination is organized, information-driven patient care activities intended to facilitate the appropriate responses to an enrolled m e m b e hrea’ lthscare needs across the continuum of care. • Value-Based Program (VBP) is an outcomes-based payment arrangement and/or a coordinated care model facilitated with one or more local providers that is evaluated against cost and quality metrics/factors and is reflected in provider payment. • Provider Incentive is an additional amount of compensation paid to a healthcare provider by us, based on the p r o v i cdomeprlia’ncse with agreed-upon procedural and/or outcome measures for a particular group of covered persons. Inter-Plan Programs: Federal/State Taxes/Surcharges/Fees Federal or state laws or regulations may require a surcharge, tax or other fee that applies to insured accounts. If applicable, we will include any such surcharge, tax or other fee as part of the claim charge passed on to you. Nonparticipating Providers Outside Our Service Area How we pay nonparticipating providers outside our service area is explained in How Non-network Providers Are Paid section above.
