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

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Claim Administrator will utilize the same Claim processing rules and/or edits that it utilizes in processing all Participating Dentist Claims for processing Claims submitted by Non-Participating Dentists which may also alter the Dental Maximum Allowance for a particular Covered Service. In the event the Dental Maximum Allowance amount does not equate to the Non-Participating Dentist's Claim Charge,a Covered Person will be responsible for the difference between such amount and the Claim Charge, along with any applicable Copayment, Coinsurance and deductible amount(s). 24.20 "Eligible Charge" means (except as otherwise provided in the next section) (a) in the case of a Provider, other than a professional Provider, which has a written agreement with Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide care to Covered Persons, or is designated as a Participating Provider by any Blue Cross and/or Blue Shield Plan, at the time Covered Services for medical benefits are rendered("Participating Provider"), such Participating 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 Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide care to a Covered Person at the time Covered Services for medical benefits are rendered ("Non-Participating Provider"), the lesser of (unless otherwise required by applicable law or arrangement with the Non-Participating Provider): L the Non-Participating Provider's Claim Charge; or ii. Claim Administrator's non-contracting Eligible Charge. Except as otherwise provided in this definition, the non-contracting Eligible Charge is developed from base Medicare reimbursements and represents approximately 100% of the base Medicare reimbursement rate and will exclude any Medicare adjustment(s)which is/are based on information on the Claim. Notwithstanding the preceding sentence, the non-contracting Eligible Charge for Coordinated Home Care Program Covered Services will be 50% of the Non-Participating Provider's standard Claim Charge for such Covered Services. The base Medicare reimbursement rate described above will exclude any Medicare adjustment(s) which is/are based on information on the Claim. When a Medicare reimbursement rate is not available for a Covered Service or is unable to be determined based on the information submitted on the Claim, the Eligible Charge for the Non-Participating Provider will be 50% of the Non-Participating Provider's standard Claim Charge for such Covered Service. Claim Administrator will utilize the same Claim processing rules, edits or methodologies that it utilizes in processing Participating Provider Claims for processing Claims submitted by Non-Participating Providers which may also alter the non-contracting Eligible Charge for a particular service. In the event Claim Administrator does not have any Claim edits, rules or methodologies, Claim Administrator may utilize the Medicare claim rules or edits that are used by Medicare in processing such Claims. The non-contracting Eligible Charge will not include any additional payments that may be permitted under the Medicare laws or regulations which are not directly attributable to a specific Claim, including, but not limited to,disproportionate share payments and graduate medical education payments. In the event the non-contracting Eligible Charge amount does not equate to the Non-Participating Provider's Claim Charge, a Covered Person will be responsible for the difference between such amount and the Claim Charge, along with any applicable Copayment, Coinsurance and deductible amount(s). Any change to the Medicare reimbursement amount will be implemented by Claim Administrator within 190 days after the effective date that such change is implemented by the Centers for Medicaid and Medicare Services, or its successor. 24.21 "Eligible Charge" shall have the following meaning effective for Covered Services rendered on or after December 1,2017: "Eligible Charge"means(a) in the case of a Provider, other than a professional Provider, which has a written agreement with Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide care to Covered Persons, or is designated as a Participating Provider by any Blue Cross and/or Blue Shield Plan, at the time Covered Services for medical benefits are rendered ("Participating Provider"), such Participating 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 Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide care to Covered Persons, or is not designated as a Participating Provider by any Blue Cross and/or Blue Shield Plan, at the time Covered Services for medical benefits are rendered ("Non-Participating Provider"), the following amount (unless otherwise required by applicable law or arrangement with the Non-Participating Provider): HCSC IL Gen ASA Med Non ERISA REG Rev.8.16 16 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.