Value-Based Programs Administration. Under Value-Based Programs, a Host Blue may pay Providers for reaching agreed-upon cost/quality goals in the following ways: retrospective settlements, Provider Incentives, a share of target savings, Care Coordinator Fees and/or other allowed amounts. The Host Blue may pass these Provider payments to Claim Administrator, which Claim Administrator will pass on to Employer in the form of either an amount included in the price of the Claim or an amount charged separately in addition to the Claim. When such amounts are included in the price of the Claim, the Claim may be billed using one of the following pricing methods, as determined by a Host Blue:
Value-Based Programs Administration. Under Value-Based Programs, a Host Blue may pay Providers for reaching agreed-upon cost/quality goals in the following ways: retrospective settlements, Provider Incentives, a share of target savings, Care Coordinator Fees and/or other allowed amounts. The Host Blue may pass these Provider payments to Anthem Blue Cross Life and Health, which Anthem Blue Cross Life and Health will pass on to Plan Sponsor in the form of either an amount included in the price of the Claim or an amount charged separately in addition to the Claim. When such amounts are included in the price of the Claim, the Claim may be billed using one of the following pricing methods: • Actual Pricing • Claim Based (Actual Pricing): The charge to accounts for Value-Based Programs incentives/Shared Savings settlements is part of the Claim. These charges are passed via an enhanced fee schedule. • Estimated/Average Pricing • Claim Based (Estimated Pricing): The charge to accounts for Value-Based Programs incentives/Shared-Savings settlements is included in the Claim as an amount based on a supplemental factor. • In such cases, Anthem Blue Cross Life and Health will pass any supplemental amounts on to Plan Sponsor as follows: it will be included as part of the Claims charge on the invoice. When such amounts are billed in addition to the Claim, they may be billed as follows: • Per Member Per Month (PMPM) Billings: Per Member Per Month xxxxxxxx for incentives/Shared-Savings settlements to accounts are outside of the Claim system. Anthem Blue Cross Life and Health will pass these Host Blue charges through to Plan Sponsor as a separately identified amount on the invoice. The amounts used to calculate either the supplemental factors or PMPM xxxxxxxx are estimates. This means that Host Blues cannot determine final amounts for these arrangements at the time when Members incur Claims for Covered Services. Consequently, Host Blues may hold some portion of the amounts Plan Sponsor pays under such arrangements until the end of the applicable Value-Based Program payment and/or reconciliation measurement period. 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 to fund Value-Based Program payments or reconciliation amount in the next measurement period. • Address any deficit in funds through an adjustment to the per-member-per-month billing amount or the reconciliation bil...
Value-Based Programs Administration. Under Value-Based Programs, a Host Blue may pay providers for reaching agreed-upon cost/quality goals in the following ways: Per member per month, provider incentives, gain share, risk share, retrospective settlements, prospective settlements, share of target savings, Care Coordination Fees and/or other allowed amounts. The Host Blue may pass these provider payments to BlueCross, which BlueCross will pass directly on to Employer as either an amount included in the price of the claim or an amount charged separately in addition to the claim. When such amounts are included in the price of the claim, the claim may be billed using one of the following pricing methods, as determined by the Host Blue: • Actual Pricing: The charge to accounts for Value-Based Programs incentives/Shared Savings settlements is part of the claim. These charges are passed to Employer via an enhanced provider fee schedule. • Supplemental Factor: The charge to accounts for Value- Based Programs incentives/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. This pricing method may be used only for non-attributed Value- Based Programs. When such amounts are billed separately from the price of the claim, they may be billed as follows:
Value-Based Programs Administration. Under Value-Based Programs, a Host Blue may pay providers for reaching agreed-upon cost/quality goals in the following ways: The Host Blue may pass these provider payments to Claims Administrator, which Claims Administrator will pass directly on to Employer as either an amount included in the price of the claim or an amount charged separately in addition to the claim. When such amounts are included in the price of the claim, the claim may be billed using one of the following pricing methods, as determined by the Host Blue:
