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

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(i) the lesser of(A)the Provider's Billed Charges, and (B) an amount determined by Claim Administrator to be approximately 100% of the base Medicare reimbursement rate, excluding any Medicare adjustment(s)which is/are based on information on the Claim; or (ii) if there is no base Medicare reimbursement rate available for a particular Covered Service, or if the base Medicare reimbursement amount cannot otherwise be determined under subsection (i) above based upon the information submitted on the Claim,the lesser of(A)the Provider's Billed Charges and (B)an amount determined by Claim Administrator to be 150% of the Maximum Allowance that would apply if the services were rendered by a Participating Professional Provider on the date of service; or (iii) if the base Medicare reimbursement amount and the Maximum Allowance cannot be determined under subsections (i) or(ii) above, based upon the information submitted on the Claim, then the amount will be 50% of the Provider's Billed Charges, provided, however, that Claim Administrator may limit such amount to the lowest contracted rate that Claim Administrator has with a Participating Provider for the same or similar service based upon the type of provider and the information submitted on the Claim, as of January 1 of the same year that the Covered Services are rendered to the Covered Person. 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. 24.22 "ERISA" means the Employee Retirement Income Security Act of 1974, as amended. 24.23 "Fee Schedule" means the fees and charges specified in the initial ASO BPA, including but not limited to, the Administrative Charge and other service charges; or subsequent fees and charges set forth in a subsequent ASO BPA as replacement or supplement to the initial ASO BPA. The Fee Schedule shall be applicable to the Fee Schedule Period therein, except that any item of the Fee Schedule may be changed in accordance with Exhibit 2. 24.24"Fee Schedule Period" means the period of time indicated in the Fee Schedule of the most current ASO BPA. 24.25"Global Payment/Total Cost of Care" means a payment methodology that is defined at the patient level and accounts for either all patient care or for a specific group of services delivered to the patient such as Outpatient, Physician, ancillary, Hospital services, and prescription drugs. 24.26 "HIPAA"means the Health Insurance Portability and Accountability Act and its implementing regulations(45 C.F.R. Parts 160-164) and the Health Information Technology for Economic and Clinical Health Act, as incorporated in the American Recovery and Reinvestment Act of 2009, and its implementing regulations, each as amended, and their respective implementing regulations, as issued and amended by the Secretary (all the foregoing, collectively"HIPAA"). 24.27"Hospital" means a duly licensed institution for the care of the sick which provides service under the care of a Physician including the regular provision of bedside nursing by registered nurses. It does not mean health resorts, rest homes, nursing homes, skilled nursing facilities, convalescent homes, custodial homes of the aged or similar institutions. 24.28 "Host Blue" means a local Blue Cross and/or Blue Shield licensee outside the geographic area that Claim Administrator serves. 24.29"Inpatient" means the Covered Person is a registered bed patient and treated as such in a health care facility. HCSC IL Gen ASA Med Non ERISA REG Rev.8.16 17 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.