Common use of Member Liability Calculation Clause in Contracts

Member Liability Calculation. The calculation of a Member’s liability on claims for covered health care services received outside of Massachusetts and processed through the BlueCard Program will be based on the provider’s actual charge or the negotiated price (allowed charge), whichever is less. Return of Overpayments. Under the BlueCard Program, recoveries from a Host Plan or from participating providers of a Host Plan can arise in several ways. These may include (but are not limited to) anti-fraud and abuse audits, provider/hospital audits, credit balance audits, utilization review refunds and unsolicited refunds. In some cases, the Host Plan will engage a third party to assist in identification or collection of recovery amounts. The fees of such a third party may be netted against the recovery. Recovery amounts determined in this way will be applied in accordance with applicable Inter-Plan Programs policies, which generally require correction on a claim-by-claim or prospective basis.