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

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b. For professional Providers who do 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): (i) the Provider's Claim Charge, or; (ii) Claim Administrator's non-contracting Maximum Allowance. Except as otherwise provided in this section, the non-contracting Maximum Allowance 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 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 Maximum Allowance for Non- Participating Professional Providers will be 100% of Claim Administrator's rate for such Covered Services according to its current Schedule of Maximum Allowances. If there is no rate according to the Schedule of Maximum Allowance then the Maximum Allowance will be 25%of Claim Charges. 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. 24.32"Negotiated Arrangement" means an agreement negotiated between one or more Blue Cross and/or Blue Shield Plans for any national account that is not delivered through the BlueCard Program. 24.33"Net Claim Payment" means the net benefit payment calculated by Claim Administrator, upon submission of a Claim, in accordance with the benefits specified in the Plan for which Claim Administrator has agreed to provide administrative services under this Agreement, 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 Claim Administrator and the particular Provider. (See provisions regarding "CLAIM ADMINISTRATOR'S SEPARATE FINANCIAL ARRANGEMENTS WITH PROVIDERS" in Exhibit 2.) 24.34"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 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 benefits coverage program(s), if applicable to the Plan under this Agreement. 24.35"Non-Participating Healthcare Provider" means a healthcare Provider that does not have a contractual agreement with a Host Blue. 24.36"Outpatient" means a Covered Person's receiving of treatment while not an Inpatient. Services considered Outpatient include, but are not limited to, services in an emergency room regardless of whether the Covered Person is subsequently registered as an Inpatient in a health care facility. HCSC IL Gen ASA Med Non ERISA REG Rev.8.16 19 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.