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:
Appears in 2 contracts
Sources: Claims Administration and Cost Management Services Agreement, Claims Administration and Cost Management Services Agreement