BlueCard® Program Clause Samples

BlueCard® Program. Under the BlueCard Program, when Members obtain Out-of-Area Covered Healthcare Services within the geographic area served by a Host Blue, Keystone will remain responsible for fulfilling Keystone’s contractual obligations. However the Host Blue is responsible for contracting with and generally handling all interactions with its participating healthcare providers. The BlueCard Program enables Members to obtain Out-of-Area Covered Healthcare Services, as defined above, from a healthcare provider participating with a Host Blue, where available. The participating healthcare provider will automatically file a claim for the Out-of-Area Covered Healthcare Services provided to the Member, so there are no claim forms for a Member to fill out. The Member will be responsible for any applicable Cost-Sharing Amounts, as outlined in the Schedule of Cost Sharing section of this Agreement.

BlueCard® Program. When a member obtains covered health care services through BlueCard outside the geographic area the Plan serves, the amount a member pays for covered services is calculated on the lower of: • The billed charges for a member’s covered services, or • The negotiated price that the on-site Blue Cross and/or Blue Shield Plan (“Host Blue”) passes on to the Plan. Often, this “negotiated price” will consist of a simple discount which reflects the actual price paid by the Host Blue. But sometimes it is an estimated price that factors into the actual price expected settlements, withholds, any other contingent payment arrangements and non-claims transactions with a member’s health care provider or with a specified group of providers. The negotiated price may also be billed charges reduced to reflect an average expected savings with a member’s health care provider or with a specified group of providers. The price that reflects average savings may result in greater variation (more or less) from the actual price paid than will the estimated price. The negotiated price will also be adjusted in the future to correct for over- or underestimation of past prices. However, the amount a member pays is considered a final price. Statutes in a small number of states may require the Host Blue to use a basis for calculating member liability for covered services that does not reflect the entire savings realized, or expected to be realized, on a particular claim or to add a surcharge. Should any state statutes mandate member liability calculation methods that differ from the usual BlueCard method noted above in paragraph one of this section or require a surcharge, the Plan would then calculate a member’s liability for any covered services in accordance with the applicable state statute in effect at the time a member received care.

BlueCard® Program. Under the BlueCard® Program, when Members access covered healthcare services within the geographic area served by a Host Blue, BCN will remain responsible to Group for fulfilling BCN's contractual obligations. However, in accordance with applicable Inter-Plan Programs policies then in effect, the Host Blue will be responsible for providing such services as contracting and handling substantially all interactions with its participating healthcare providers. The financial terms of the BlueCard Program are described generally below. Individual circumstances may arise that are not directly covered by this description; however, in those instances, our action will be consistent with the spirit of this description.

BlueCard® Program. The Group will pay to Anthem the following Administrative Fees determined in accordance with the applicable rules of the Blue Cross Blue Shield Association for the use of Out-of-California Providers under the BlueCard Program: Institutional Claims $ 11.00 Professional Claims $ 5.00 Central Financial Agency Fee $ .20 Charge per transaction $ .05 Electronic Claims Routing Process (ECRP) (non-participating provider claims) $ 1.00 These fees are subject to change in accordance with the applicable rules of the Blue Cross Blue Shield Association.

BlueCard® Program. Anthem is a member of the Blue Cross Blue Shield Association. The Blue Cross Blue Shield Association has a program (called the “BlueCard Program”) which allows our Members who are traveling outside of California to have the reciprocal use of participating providers contracted under other states’ Blue Cross Blue Shield plans. There are fees associated with the reciprocal use of such providers by Members and are determined in accordance with the applicable rules of the Blue Cross Blue Shield Association which will be charged back to the Group. These fees are:

BlueCard® Program. Ancillary Provider acknowledges and agrees that, pursuant to BCBSTX’s BlueCard Program, Ancillary Provider shall provide Covered Services to Subscribers covered through the BlueCard Program while such Subscribers are in the BCBSTX service area as set forth in this Agreement and subject to the same terms and conditions of this Agreement as are applicable to provision of Covered Services to other Subscribers.

BlueCard® Program. Under the BlueCard Program, when Members access covered healthcare services within the geographic area served by a Host Blue, Highmark Delaware will remain responsible to Group for fulfilling our contractual obligations. However, in accordance with applicable Inter-Plan Programs policies then in effect, the Host Blue will be responsible for providing such services as contracting and handling substantially all interactions with its participating healthcare providers. The financial terms of the BlueCard Program are described generally below. Individual circumstances may arise that are not directly covered by this description; however, in those instances, our action will be consistent with the spirit of this description.

BlueCard® Program. For Members participating in the BlueCard Program, Group may refer to the back of the Member's identification card for information regarding authorization requirements.

BlueCard® Program. Under the BlueCard® Program, when you receive covered healthcare services within the geographic area served by a Host Blue, CareFirst will remain responsible for doing what we agreed to in the contract. However, the Host Blue is responsible for contracting with and generally handling all interactions with its participating providers. When you receive covered healthcare services outside the CareFirst service area and the claim is processed through the BlueCard Program, the amount you pay for covered healthcare services is calculated based on the lower of: • The billed charges for Covered Services; or • The negotiated price that the Host Blue makes available to CareFirst. Often, this “negotiated price” will be a simple discount that reflects an actual price that the Host Blue pays to your healthcare provider. Sometimes, it is an estimated price that takes into account special arrangements with your healthcare provider or provider group that may include types of settlements, incentive payments and/or other credits or charges. Occasionally, it may be an average price, based on a discount that results in expected average savings for similar types of healthcare providers after taking into account the same types of transactions as with an estimated price. Estimated pricing and average pricing also take into account adjustments to correct for over- or underestimation of past pricing of claims, as noted above. However, such adjustments will not affect the price CareFirst has used for your claim because they will not be applied after a claim has already been paid.