Liability Calculation Method Per Claim Clause Samples

Liability Calculation Method Per Claim. Unless subject to a fixed dollar copayment, the calculation of the Enrolled Member liability on claims for covered healthcare services will be based on the lower of the participating provider's billed covered charges or the negotiated price made available to BCBSRI by the Host Blue. Host Blues determine a negotiated price, which is reflected in the terms of each Host Blue’s healthcare provider contracts. The negotiated price made available to BCBSRI by the Host Blue may be represented by one of the following: (i) An actual price. An actual price is a negotiated rate of payment in effect at the time a claim is processed without any other increases or decreases; or (ii) An estimated price. An estimated price is a negotiated rate of payment in effect at the time a claim is processed, reduced or increased by a percentage to take into account certain payments negotiated with the provider and other claim- and non-claim-related transactions. Such transactions may include, but are not limited to, anti-fraud and abuse recoveries, provider refunds not applied on a claim-specific basis, retrospective settlements and performance- related bonuses or incentives; or (iii) An average price. An average price is a percentage of billed covered charges in effect at the time a claim is processed representing the aggregate payments negotiated by the Host Blue with all of its healthcare providers or a similar classification of its providers and other claim- and non-claim-related transactions. Such transactions may include the same ones as noted above for an estimated price. Host Blues determine whether or not they will use an actual, estimated or average price. Host Blues using either an estimated price or an average price may prospectively increase or reduce such prices to correct for over- or underestimation of past prices (i.e., prospective adjustment may mean that a current price reflects additional amounts or credits for claims already paid or anticipated to be paid to providers or refunds received or anticipated to be received from providers). However, the BlueCard Program requires that the amount paid by the Enrolled Member is a final price; no future price adjustment will result in increases or decreases to the pricing of past claims. The method of claims payment by Host Blues is taken into account by BCBSRI in determining your premiums.

Liability Calculation Method Per Claim. The calculation of a Member's liability on claims for covered health care services incurred outside the geographic area BCBSM serves and processed through BlueCard will be based on the lower of the provider's billed charges or the negotiated price BCBSM pays the Host Plan. The methods employed by a Host Plan to determine a negotiated price will vary among Host Plans based on the terms of each Host Plan's provider contracts. The negotiated price paid to a Host Plan by BCBSM on a claim for health care services processed through BlueCard may represent:

Liability Calculation Method Per Claim. The calculation of the member copay, if not a flat dollar copay, for out-of-area covered healthcare services processed through the BlueCard Program will be based on the lower of the participating healthcare provider's billed covered charges or the negotiated price made available to Anthem by the Host Blue. Host Blues may use various methods to determine a negotiated price, depending on the terms of each Host Blue’s healthcare provider contracts. The negotiated price made available to Anthem by the Host Blue may represent a payment negotiated by a Host Blue with a healthcare provider that is one of the following:

Liability Calculation Method Per Claim. The calculation of the Participant liability on claims for Covered Services processed through the BlueCard® Program will be based on the lower of the participating healthcare provider's billed covered charges or the negotiated price made available to Service Provider by the Host Plan. The calculation of the Department’s liability on claims for Covered Services processed through the BlueCard® Program will be based on the negotiated price made available to Service Provider by the Host Plan. This negotiated price may be greater than what would be the healthcare provider(s)’ billed charges in those instances where the Host Plan has negotiated with its participating healthcare provider(s) an inclusive allowance for specific healthcare services (e.g., DRG or per case or per day amount payment methodologies). Each Host Plan’s determination of an applicable negotiated price will be consistent with the terms of each Host Plan’s applicable healthcare provider contract. The negotiated price made available to Service Provider by the Host Plan which will be passed through to the Department under this Contract is one of the following: (i) an actual price. An actual price is a negotiated payment without any other increases or decreases, or (ii) an estimated price. An estimated price is a negotiated payment reduced or increased by a percentage to take into account certain payments negotiated with the provider and other claim- and non-claim-related transactions. Such transactions may include, but are not limited to, anti-fraud and abuse recoveries, provider refunds not applied on a claim-specific basis, retrospective settlements, and performance-related bonuses or incentives, or (iii) an average price. An average price is a percentage of billed covered charges representing the aggregate payments negotiated by the Host Plan with all of its healthcare providers or a similar classification of its providers and other claim- and non-claim-related transactions. Such transactions may include the examples noted above for an estimated price. Host Plans using either an estimated price or an average price may, in accordance with BlueCard® policies, prospectively increase or reduce such prices to correct for over- or underestimation of past prices (i.e., prospective adjustments may mean that a current price reflects additional amounts or credits for claims already paid to providers or anticipated to be paid to or received from providers). However, the amount paid by the Participant an...

Liability Calculation Method Per Claim. The calculation of Subscriber liability on claims for covered health care services incurred outside the geographic area Blue Shield of California serves, and processed through BlueCard will be based on the lower of the provider's billed charges or the negotiated price Blue Shield of California pays the Host Blue. The methods employed by a Host Blue to determine a negotiated price will vary among Host Blues based on the terms of each Host Blue’s provider contracts. The negotiated price paid to a Host Blue by Blue Shield of California on a claim for health care services processed through BlueCard may represent:

Liability Calculation Method Per Claim. The calculation of the Member liability on claims for covered healthcare services processed through the BlueCard Program will be based on the lower of the participating healthcare provider's billed covered charges or the negotiated price made available to Highmark Delaware by the Host Blue. The calculation of Group's liability on claims for covered healthcare services processed through the BlueCard Program will be based on the negotiated price made available to Highmark Delaware by the Host Blue. Sometimes, this negotiated price may be greater than billed charges if the Host Blue has negotiated with its participating healthcare provider(s) an inclusive allowance (e.g., per case or per day amount) for specific healthcare services. Host Blues may use various methods to determine a negotiated price, depending on the terms of each Host Blue’s healthcare provider contracts. The negotiated price made available to Highmark Delaware by the Host Blue may represent a payment negotiated by a Host Blue with a healthcare provider that is one of the following:

Liability Calculation Method Per Claim. The calculation of Participant liability on claims for covered health care services incurred outside the geographic area Blue Shield serves, and processed through BlueCard will be based on the negotiated price Blue Shield pays the Host Blue. The calculation of County liability on claims for covered health care services incurred outside the geographic area Blue Shield serves, and processed through BlueCard will be based on the negotiated price Blue Shield pays the Host Blue. The methods employed by a Host Blue to determine a negotiated price will vary among Host Blues based on the terms of each Host Blue’s provider contracts. The negotiated price paid to a Host Blue by Blue Shield on a claim for health care services processed through BlueCard may represent:

Liability Calculation Method Per Claim. The calculation of the Plan Participant liability on claims for covered health care services processed through the BlueCard Program, if not a flat dollar copayment, will be based on the lower of the participating health care provider's billed covered charges or the negotiated price made available to Contractor by the Host Blue. The calculation of County liability on claims for covered health care services processed through the BlueCard Program will be based on the negotiated price made available to Contractor by the Host Blue. Sometimes, this negotiated price may be greater than billed charges if the Host Blue has negotiated with its participating health care provider(s) an inclusive allowance (e.g., per case or per day amount) for specific health care services. Host Blues may use various methods to determine a negotiated price, depending on the terms of each Host Blue’s health care provider contracts. The negotiated price made available to Contractor by the Host Blue may represent a payment negotiated by a Host Blue with a health care provider that is one of the following:

Liability Calculation Method Per Claim. The calculation of Member liability on Claims for covered services processed through the BlueCard Program will be based on the lower of the provider’s billed charges or the negotiated price made available to Contractor by the Host Blue. The calculation of HCA liability on Claims for covered services processed through BlueCard will be based on the negotiated price made available to Contractor by the Host Blue. Sometimes, this negotiated price may be greater than billed charges if the Host Blue has negotiated with its participating healthcare provider(s) an inclusive allowance (e.g., per case or per day amount) for specific healthcare services.