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

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24.30"Maximum Allowance" means (except as otherwise provided in the next section) in the case of a professional Provider one of the following amounts in accordance with the type of medical benefits coverage elected on the most current ASO BPA: a. For a professional Provider who has a written agreement with Claim Administrator or another Blue Cross and/or Blue Shield Plan or is designated as a Participating Provider by any Blue Cross and/or Blue Shield Plan, to provide care to Covered Persons at the time Covered Services for medical benefits are rendered ("Participating Professional Provider"), the amount such Participating Professional Provider has agreed to accept as payment in full for a particular Covered Service. All benefit payments for Covered Services rendered by a Participating Professional Provider will be based on the Schedule(s)of Maximum Allowances which such Provider has agreed to accept as payment in full. b. For a professional Provider who does not have a written agreement with Claim Administrator or another Blue Cross and/or Blue Shield Plan or is not designated as a Participating Provider by any Blue Cross and/or Blue Shield Plan, to provide care to Covered Persons at the time Covered Services for medical benefits are rendered ("Non-Participating Professional Provider"), the lesser of (unless otherwise required by applicable law or arrangement with the Non-Participating Provider) the Non-Participating Professional Provider's Claim Charge or Claim Administrator's non-contracting Maximum Allowance amount which is developed from base Medicare reimbursements and represents approximately 100% of the base Medicare reimbursement rate, excluding any Medicare adjustment(s)which is/are based on information on the Claim. Notwithstanding the preceding sentence, the non-contracting Maximum Allowance for Coordinated Home Care Program Covered Services will be 50% of the Non-Participating Professional Provider's standard Claim Charge for such Covered Services. 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 non-contracting Maximum Allowance will be 50% of the Non-Participating Professional 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 Professional Provider Claims for processing Claims submitted by Non- Participating Professional Providers which may also alter the non-contracting Maximum Allowance for a particular Covered 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 Maximum Allowance 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 Maximum Allowance amount does not equate to the Non-Participating Professional 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. 24.31 "Maximum Allowance"shall have the following meaning effective for Covered Services rendered on or after December 1, 2017: "Maximum Allowance" means in the case of a professional Provider one of the following amounts in accordance with the type of medical benefits coverage elected on the most current ASO BPA: a. For professional Providers who have a written agreement with Claim Administrator or another Blue Cross and/or Blue Shield Plan or is designated as a Participating Provider by any Blue Cross and/or Blue Shield Plan to provide care to Covered Persons at the time Covered Services for medical benefits are rendered("Participating Professional Provider"),the amount such Participating Professional Provider has agreed to accept as payment in full,or the reimbursement amount set by Claim Administrator or the Host Blue Plan for Providers designated as Participating Professional Providers for a particular Covered Service. All benefit payments for Covered Services rendered by a Participating Professional Provider will be based on the Schedule of Maximum Allowances which such Provider have agreed to accept as payment in full. HCSC IL Gen ASA Med Non ERISA REG Rev.8.16 18 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.