R2007-236 AUTHORIZING AGREEMENT WITH BLUE CROSS BLUE SHIELD OF ILLINOIS

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l 1 � "' 2.5 "Claim Charge" means the amount which appears on a Claim as the Provider's regular charge for service rendered to a patient,without further adjustment or reduction and irrespective of any separate financial arrangement between the Claim Administrator and the particular Provider. (See provisions regarding "CLAIM ADMINISTRATOR'S SEPARATE FINANCIAL ARRANGEMENTS WITH PROVIDERS"in Exhibit 2 of this Agreement.) 2.6 "Claim Payment"means the benefit calculated by the Claim Administrator,plus any related Surcharges,upon submission of a Claim,in accordance with the benefits specified in the Plan.All Claim Payments shall be calculated on the basis of the Provider's Eligible Charge for Covered Services rendered to the Covered Person, irrespective of any separate financial arrangement between the Claim Administrator and the particular Provider. (See provisions regarding "CLAIM ADMINISTRATOR'S SEPARATE FINANCIAL ARRANGEMENTS WITH PROVIDERS" in Exhibit 2 of this Agreement.) 2.7 "Covered Employee"shall have the same meaning as defined in the Employer's Plan. 2.8 "Covered Person"shall have the same meaning as defined in the Employer's Plan. 29 "Covered Service"means a service or supply specified in the Plan for which benefits will be provided. 2.10"Eligible Charge"means(a)in the case of a Provider other than a professional Provider which has a written agreement with the Claim Administrator to provide care to a Covered Person at the time Covered Services are rendered, such Provider's Claim Charge for Covered Services and(b)in the case of a Provider other than a professional Provider which does not have , a written agreement with the Claim Administrator to provide care to a Covered Person at the time Covered Services are ; rendered,the amount for Covered Services determined by the Claim Administratar based on the following order: a. The charge which is within the range of charges other similar hospitals or facilities in similar geographic areas ', charge their patients for the same or similar services,as reasonably determined by the Claim Administrator,if available;or , b. The amount that Centers for Medicare&Medicaid Services("CMS")reimburses hospitals or facilities in li similar geographic areas for the same or similar services rendered to members in the Medicare program; or �i c. The charge which the particular hospital or facility usually charges its patients for Covered Services. '� 211 "ERISA"means the Employee Retirement Income Security Act of 1974,as amended. 2.12"Fee Schedule"means the specifications setting out certain particulars of this Agreement under Exhibit 2 of this Agreement including, but not limited to, the Administrative Charge and other service charges; or any such other subsequent set of specifications supplied by the Claim Administrator as a replacement to the Fee Schedule under Exhibit 2.The specifications or items of the Fee Schedule shall be applicable for the Fee Schedule Period noted therein,except that any item of the Fee Schedule may be changed in accordance with such Exhibit's "COMPENSATION TO CLAIM ADMINISTRATOR" provisions. 2.13"Fee Schedule Period"means the period of time beginning and ending on the dates shown in the most current Fee Schedule under Exhibit 2 of this Agreement. 214 "Group Health Plan"means, as applied to this Agreement,the self-insured employee welfare benefit plan as defined by Section 160.103 of the Health Insurance Portability and Accountability Act of 1996. 2.15"HIPAA"means the Health Insurance Portability and Accountability Act of 1996. 2.16"Net Claim Payment"means the net benefit payment calculated by the Claim Administrator,upon submission of a Claim, in accordance with the benefits specified in the Plan, plus any related Surcharges. All Net Claim Payments shall be calculated on the basis of the Provider's Eligible Charge for Covered Services rendered to the Covered Person,less the ADP if applicable, irrespective of any separate financial arrangement between the Claim Administrator and the particular Provider. (See provisions regarding "CLAIM ADMINISTRATOR'S SEPARATE FINANCIAL ARRANGEMENTS WITH PROVIDERS"in Exhibit 2 of this Agreement.) 2.17 "Network" means identified Providers, including physicians, other professional health care providers,hospitals, ancillary providers, and other health care facilities, that have entered into agreements with the Claim Administrator(and, in some instances,with other participating Blue Cross and/or Blue Shield Plans)for participation in a participating provider option and/or point-of-service managed care health benefit coverage program(s),if applicable to the Plan under this Agreement. -6-