R2016-136 BlueCross BlueShield Administration of Group Health Benefit Plan 2017

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made using (i)the estimated number of members involved in a particular Arrangement (as of the end of the month preceding the calculation), and (ii) the estimated Alternative Compensation Arrangement Payments for all such members. Expected Payment may vary from member to member. Employer will be billed for its share of the Expected Payment.Any difference(surplus or deficit) between the Expected Payments that Employer has made to Claim Administrator and actual Alternative Compensation Arrangement Payments will be factored into Claim Administrator's calculation of future Expected Payments. Interest on such difference (surplus or deficit) will be credited (or charged) to Employer and included in the calculation of future Expected Payments. Claim Administrator may recalculate the PMPM charge from time to time in a manner consistent with this Agreement. In the case of any such modification, Claim Administrator shall inform Employer of such modifications Employer will be deemed to have approved the modifications, which will become part of this Agreement. 24.4 "Average Discount Percentage ("ADP")" means a percentage discount determined by Claim Administrator that will be applied to a Provider's Eligible Charge for Covered Services rendered to Covered Persons by Hospitals and certain other health care facilities for purposes of calculating Coinsurance amounts, deductibles, out—of—pocket maximums and/or any benefit maximums. The ADP will often vary from Claim to Claim. The ADP applicable to a particular Claim for Covered Services is the ADP, current on the date the Covered Service is rendered,that is determined by Claim Administrator to be relevant to the particular Claim. The ADP reflects Claim Administrator's reasonable estimate of average payments, discounts and/or other allowances that will result from its contracts with Hospitals and other facilities under circumstances similar to those involved in the particular Claim, reduced by an amount, not to exceed fifteen percent (15%) of such estimate, to reflect related costs. (See provisions regarding "CLAIM ADMINISTRATOR'S SEPARATE FINANCIAL ARRANGEMENTS WITH PROVIDERS" in Exhibit 2.) In determining the ADP, Claim Administrator will take into account differences among Hospitals and other facilities, Claim Administrator's contracts with Hospitals and other facilities, the nature of the Covered Services involved and other relevant factors. The ADP shall not apply to Eligible Charges when the Covered Person's benefits under the Plan are secondary to Medicare and/or coverage under any other group program. 24.5 "BlueCard Worldwide Access Vendor Fees"means the charges to Claim Administrator for the transaction fees through the BlueCard® Worldwide program which are payable to the medical assistance vendor for assisting Covered Persons traveling or living outside of the United States, Puerto Rico, and U.S. Virgin Islands to obtain medical services. 24.6 "Care Coordination" means organized, information-driven patient care activities intended to facilitate the appropriate responses to Covered Person's healthcare needs across the continuum of care. 24.7 "Care Coordinator" means an individual within a Provider organization who facilitates Care Coordination for patients. 24.8 "Care Coordinator Fee" means a fixed amount paid by a BlueCross and/or Blue Shield Plan to Providers periodically for Care Coordination under a Value-Based Program. 24.9 "Claim" means a properly completed notification in a form acceptable to Claim Administrator, including but not limited to, form and content required by applicable law, that service has been rendered or furnished to a Covered Person.This notification must set forth in full the details of such service including, but not limited to, the Covered Person's name, age, sex and identification number, the name and address of the Provider, a specific itemized statement of the service rendered or furnished (including appropriate codes), the date of service, applicable diagnosis (including appropriate codes), the Claim Charge, and any other information which Claim Administrator may request in connection for such service. 24.10"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 Claim Administrator and the particular Provider. (See provisions regarding "CLAIM ADMINISTRATOR'S SEPARATE FINANCIAL ARRANGEMENTS WITH PROVIDERS" in Exhibit 2. 24.11 "Claim Payment" means the benefit calculated by Claim Administrator, plus any related Surcharges, upon submission of a Claim, in accordance with the benefits specified in the Plan for which Claim Administrator has agreed to provide administrative services. All Claim Payments shall be calculated on the basis of the Provider's Eligible Charge, Maximum Allowance, Prescription Drug Program Eligible Charge and/or Dental Maximum Allowance, in accordance with the benefit coverage(s) elected on the most current ASO BPA, for Covered Services rendered to the Covered Person, irrespective of any separate financial arrangement HCSC IL Gen ASA Med Non ERISA REG Rev.8.16 14 Proprietary and Confidential Information of Claim Administrator Not for use or disclosure outside Claim Administrator,Employer,their respective affiliated companies and third party representatives,except with written permission of Claim Administrator.