Eligible Charge definition

Eligible Charge means any necessary, reasonable, and customary item of which at least a portion is covered under this Plan, but does not include:

Eligible Charge means (a) in the case of a Provider, other than a Professional Provider, which has a written agreement with Blue Cross and Blue Shield of Illinois or another Blue Cross and/or Blue Shield Plan to provide care to participants in the benefit program, or is designated as a Participating Provider by any Blue Cross and/or Blue Shield Plan, at the time Covered Services are rendered, such Provider’s Claim Charge for Covered Services and (b) in the case of a Provider, other than a Professional Provider, which does not have a written agreement with Blue Cross and Blue Shield of Illinois or another Blue Cross and/or Blue Shield Plan to provide care to participants in the benefit program, or is not designated as a Participating Provider by any Blue Cross and/or Blue Shield Plan, at the time Covered Services are rendered, the following amount (unless otherwise required by applicable law or arrangement with the Non- Participating Provider):

Eligible Charge means the treating health care provider's usual, customary and reasonable charge or the upper limit of the medical fee schedule as found in N.J.A.C. 11:3-29.6, whichever is lower.

Examples of Eligible Charge in a sentence

• All Claim Payments will be calculated on the basis of the Eligible Charge for Covered Services rendered to you, regardless of any separate financial arrangement between the Claim Administrator and a particular Provider.

• AVERAGE DISCOUNT PERCENTAGE (“ADP”).....means a percentage discount determined by the Claim Administrator that will be applied to a Provider’s Eligible Charge for Covered Services rendered to you by Hospitals and certain other health care facilities for purposes of calculating Coinsurance amounts, deductibles, out-of-pocket maximums and/or any benefit maximums.

• The following expenses for Covered Services cannot be applied to the out-of-pocket expense limit and will not be paid at 100% of the Eligible Charge or Maximum Allowance when your out-of-pocket expense limit is reached: 1.

• Non‐Plan ProviderWhen you receive Outpatient Hospital Covered Services from a Non‐Plan Pro­ vider, benefits will be provided at 50% of the Eligible Charge after you have met your program deductible.

• The Eligible Charge will not include any additional payments that may be permitted under the Medicare laws or regulations which are not directly attributable to a specific Claim, including, but not limited to, disproportionate share payments and graduate medical education payments.

More Definitions of Eligible Charge

Eligible Charge means (a) in the case of a Provider which has a written agreement with the Plan or the entity chosen by the Plan to administer its prescription drug program to provide Covered Services to you at the time you receive the Covered Services, such Provider's Claim Charge for Covered Services and (b) in the case of a Provider which does not have a written agreement with the Plan or the entity chosen by the Plan to provide services to you at the time you receive Covered Services, either of the following charges for Covered Services:

Eligible Charge means (a) in the case of a Provider which has a written agreement with a Blue Cross and Blue Shield Plan or the entity chosen by Blue Cross and Blue Shield to administer its prescription drug program to provide Covered Services to you at the time you receive the Covered Services, such Provider’s Claim Charge for Cov- ered Services and (b) in the case of a Provider which does not have a written agreement with a Blue Cross and Blue Shield Plan or the entity chosen by Blue Cross and Blue Shield to provide services to you at the time you receive Covered Services, either of the following charges for Covered Services:

Eligible Charge means the charge determined by the Trust Fund according to the criteria in Section 3.7 and is the charge used to calculate the benefit payment for a covered service.

Eligible Charge means the lower of Provider’s billed charge or the agreed upon amount for reimbursement that Provider shall receive for Covered Services to Eligible Persons. UHA’s actual payment to Provider shall be less the Eligible Person’s Copayment.

Eligible Charge means any charge against a person on or after January 1, 2027, if the records relating to the charge are eligible to be sealed pursuant to subsection 1 of NRS 179.255 for a drug-related charge, including, without limitation, a charge pursuant to paragraph (c) or (g) of subsection 1 of NRS 179.245, for a drug- related conviction charge ,including, without limitation, a conviction charge pursuant to paragraph (a) of subsection 2 of NRS 453.336, subsection 4 or 5 of NRS 453.336, subsection 2 of NRS 453.3393 or NRS 453.560 or 454.351.

Eligible Charge means (1) in the case of a Provider which has a written agreement with the Plan to provide care to a Covered Person at the time Covered Services are rendered, such Provider’s Claim Charge for Covered Services and (2) in the case of a Provider which does not have a written agreement with the Plan to provide care to a Covered Person at the time Covered Services are ren- dered, either of the following charges for Covered Services as determined at the discretion of the Plan:

Eligible Charge means any necessary, reasonable and customary item of which at least a portion is covered under the Medical Insurance Plan, but does not include charges specifically excluded from benefits under the Medical Insurance Plan that also may be eligible under any other plans covering the individual for whom the claim is made.