Value-Based Programs Sample Clauses
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. 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. • 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 provider’s billed charge. This may occur in situations where an enrolled member did not have reasonable acces...
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. 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. How we pay nonparticipating providers outside our service area is explained in How
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. 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. 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.
Value-Based Programs. 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. 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. BlueCard Program
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. 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. 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. Value-Based Programs Overview: Value-Based Programs under the BlueCard Program/Value-Based Programs Administration:
(a) Actual Pricing: The charge to accounts for Value-Based Programs incentives/provider shared savings settlements is part of the claim. These charges are passed to Plan Sponsor, Plan Administrator, and/or Group Health Plan via an enhanced provider fee schedule.
(b) Supplemental Factor: The charge to accounts for Value-Based Programs incentives/provider shared savings settlements is a supplemental amount that is included in the claim as an amount based on a specified supplemental factor (e.g., a small percentage increase in the claim amount). The supplemental factor may be adjusted from time to time. When such amounts are billed separately from the price of the claim, they may be billed as follows: • Per Member Per Month (PMPM) Billings: Per Member Per Month xxxxxxxx for Value- Based Programs incentives/provider shared savings settlements to accounts are outside of the claim system. BCBSNC will pass these Host Blue charges directly through to Plan Sponsor, Plan Administrator, and/or Group Health Plan as a separately identified amount on the group xxxxxxxx. DRAFT The amounts used to calculate either the supplemental factors for estimated pricing or PMPM xxxxxxxx are fixed amounts that are estimated to be necessary to finance the cost of a particular Value-Based Program. Because amounts are estimates, there may be positive or negative differences based on actual experience, and such differences will be accounted for in a variance account maintained by the Host Blue (in the same manner as described in the BlueCard claim pricing section above) until the end of the applicable Value-Based Program payment and/or reconciliation measurement period. The amounts needed to fund a Value-Based Program may be changed before the end of the measurement period if it is determined that amounts being collected are projected to exceed the amount necessary to fund the program or if they are projected to be insufficient to fund the program. At the end of the Value-Based Program payment and/or reconciliation measurement period for these arrangements, Host Blues will take one of the following actions: • Use any surplus in funds in the variance account to fund Value-Based Program payments or reconciliation amounts in the next measurement period. • Address any deficit in funds in the variance account through an adjustment to the PMPM billing amount or the reconciliatio...
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. 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. 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. 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. How we pay nonparticipating providers outside our service area is explained in How