Maximum Allowable Charge means the benefit payable for a specific coverage item or benefit under the Plan. The Maximum Allowable Charge will always be a negotiated rate, if one exists; if no negotiated rate exists, the Maximum Allowable Charge will be determined and established by the Plan, at the Plan Administrator's discretion, using normative data and submitted information such as, but not limited to, any one or more of the following, in the Plan Administrator’s discretion:
Maximum Allowable Charge means the amount payable for a specific covered item under this Plan. The Maximum Allowable Charge will be a negotiated rate, if one exists.
Maximum Allowable Charge means the benefit payable for a specific coverage item or benefit under this Plan. The Maximum Allowable Charge will be a negotiated rate, if one exists.With respect to Out-of-Network Services, the Plan Administrator will pay up to Plan’s Maximum Allowable Charge (reduced for cost-sharing). Below are Maximum Allowable rates.• Professional – 100% the allowable rate of Medicare rates.• Facility – 100% the allowable rate of Medicare rates.• If there is no negotiated rate for a given service, there will be no allowed reimbursement.With respect to In-Network Services, the Plan Administrator will pay up to Plan’s Maximum Allowable Charge (reduced for cost-sharing).• Professional – Services will be reimbursed according to contractual agreement.• Facility – Services will be reimbursed according to contractual agreement.• If and only if there is no negotiated rate for a given service, the Plan Administrator will exercise its discretion to determine the Maximum Allowable Charge based on any of the following:— Medicare reimbursement rates.— Medicare cost data, amounts actually collected by providers in the area for similar services, or average wholesale price (AWP) or manufacturer’s retail pricing (MRP).These ancillary factors will take into account generally-accepted billing standards and practices.
Examples of Maximum Allowable Charge in a sentence
As such this Plan may pay benefits that are later found to be greater than the Maximum Allowable Charge.
Billed Charges may be different from the amount that We determine to be the Maximum Allowable Charge for services.
Benefits will be limited to the applicable Transplant Maximum Allowable Charge (TMAC).
The Deductible(s) will apply to the applicable Out-of-Pocket Maximum(s).Copayments, Coinsurance, Penalties and any balance of charges (the difference between Billed Charges and the Maximum Allowable Charge) are not considered when determining if You have satisfied the applicable Deductible.
You may always elect to receive services that do not comply with BlueCross’s Care Management requirements or Utilization Policy, but doing so may affect the Coverage of such services.A. Prior AuthorizationSome Covered Services must be Authorized by BlueCross in advance in order to be paid at the Maximum Allowable Charge without Penalty.
More Definitions of Maximum Allowable Charge
Maximum Allowable Charge means the maximum reimbursement payable to a Participating Provider for Covered Services under the terms of this Contract.
Maximum Allowable Charge means a limitation on the billed charge as determined by the Plan by geographic area where the expenses are incurred.
Maximum Allowable Charge means the benefit payable for a specific coverage item or benefit under this Plan. The Maximum Allowable Charge will be a negotiated rate, if one exists.
Maximum Allowable Charge means the following: (a) a usual fee is defined as the charge made for a given service by a Doctor to the majority of his patients; and (b) a customary fee is one which is charged by the majority of Doctors within a community for the same services. All benefits are limited to Usual and Customary Charges.
Maximum Allowable Charge means the highest dollar amount of reimbursement allowed by either the primary or secondary plan for a particular covered service. Such amount is based on the fees negotiated between the claims administrator and certain physicians, health care professionals or other providers and whether covered services are received from providers contracting with the claims administrator or not contracting with the claims administrator. Reimbursement for services provided by non-contracting providers will be the stated percentage of the maximum allowable charge or billed charges, whichever is less. Contracting providers shall mean providers contracting with the claims administrator or one of its affiliates.
Maximum Allowable Charge means the benefit payable for a specific coverage item or benefit under the Plan. The Maximum Allowable Charge will always be a negotiated rate, if one exists. If no negotiated rate exists, the Maximum Allowable Charge will be determined as follows.
Maximum Allowable Charge means, with respect to a charge by a Network Provider, the charge that is established by an agreement between the Plan and the Network Providers.