Common use of For non-network providers Clause in Contracts

For non-network providers. For a Provider who does not have a written agreement with Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide care to a Covered Person at the time Covered Services for medical benefits are rendered (“Non- Network Provider”), the Allowable Amount for Non-Network Providers is developed from base Medicare reimbursements, excluding any Medicare adjustments using information on the Claim, and adjusted by a predetermined factor established by the Plan. Such factor will not be less than one-hundred percent (100%) of the base Medicare reimbursement rate unless a lower factor has been negotiated with the Non-Network Provider. For services for which a Medicare reimbursement rate is not available, the Allowable Amount for Non- Network Providers will represent an average contract rate for Network Providers adjusted by a predetermined factor established by the Plan and updated on a periodic basis. Such factor shall not be less than eighty percent (80%) of the average contract rates and will be updated not less than every two years. Claim Administrator will utilize the same Claim processing rules and/or edits that it utilizes in processing Network Provider Claims for processing Claims submitted by Non-Network Providers which may also alter the Allowable Amount for a particular service. In the event the Plan does not have any Claim edits or rules, the Plan may utilize the Medicare claim rules or edits that are used by Medicare in processing the Claims. The Allowable Amount 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 and graduate medical education payments. Any change to the Medicare reimbursement amount will be implemented by the Plan within ninety (90) days after the effective date that such change is implemented by the Centers for Medicaid and Medicare Services, or its successor.

For non-network providers. For a Provider who does not have a written agreement with Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide care to a Covered Person at the time Covered Services for medical benefits are rendered (“Non- Non-Network Provider”), the Allowable Amount for will be the lesser of: (a) the Non-Network Providers Provider's Claim Charge, or; (b) Claim Administrator’s non-contracting Allowable Amount. Except as otherwise provided in this section ii, the non-contracting Allowable Amount is developed from base Medicare reimbursements, excluding any Medicare adjustments using information on the Claim, and reimbursements adjusted by a predetermined factor established by the PlanClaim Administrator. Such factor will shall be not be less than one-hundred percent (100%75% and will exclude any Medicare adjustment(s) of which is/are based on information on the base Medicare reimbursement rate unless a lower factor has been negotiated with the Non-Network ProviderClaim. For services for which When a Medicare reimbursement rate is not availableavailable or is unable to be determined based on the information submitted on a Claim, the non-contracting Allowable Amount for Non- Non-Network Providers will represent an average contract rate in aggregate for Network Providers adjusted by a predetermined factor established by the Plan and updated on a periodic basisClaim Administrator. Such factor shall be not be less than eighty percent (80%) of the average contract rates 75% and will shall be updated not less than every two years. Claim Administrator will utilize the same Claim processing rules and/or edits that it utilizes in processing Network Provider Claims for processing Claims submitted by Non-Network Providers which may also alter the Allowable Amount for a particular serviceCovered Service. In the event the Plan Claim Administrator does not have any Claim edits or rules, the Plan Claim Administrator may utilize the Medicare claim rules or edits that are used by Medicare in processing the Claims. The Allowable Amount 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 including, but not limited to, disproportionate share and graduate medical education payments. Any change to the Medicare reimbursement amount will be implemented by the Plan Claim Administrator within ninety (90) days after the effective date that such change is implemented by the Centers for Medicaid and Medicare Services, or its successor. The non-contracting Allowable Amount does not equate to the Provider's Claim Charge and Covered Persons receiving Covered Services from a Non-Network Provider will be responsible for the difference between the non-contracting Allowable Amount and the Non-Network Provider's Claim Charge, and this difference may be considerable. To find out Claim Administrator’s non-contracting Allowable Amount for a particular Covered Service, Covered Persons may call customer service at the number on the back of Claim Administrator-issued identification card.