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12/06/2016 (2)
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12/06/2016 (2)
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Last modified
12/10/2020 1:47:03 PM
Creation date
2/21/2017 1:24:25 PM
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Meetings
Meeting Type
BCC Regular Meeting
Document Type
Agenda Packet
Meeting Date
12/06/2016
Meeting Body
Board of County Commissioners
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emergency services will be governed by applicable federal and state law. <br />b. Exceptions <br />In some exception cases, at Employer's direction, Florida Blue may pay claims from <br />nonparticipating healthcare providers outside of Florida Blue's service area based on <br />the provider's billed charge. This may occur in situations where a member did not <br />have reasonable access to a participating provider, as determined by Florida Blue (in <br />Florida Blue's sole and absolute discretion) or by applicable state law. In other <br />exception cases, (at Employer's direction) Florida Blue may pay such claims based <br />on the payment Florida Blue would make if Florida Blue were paying a <br />nonparticipating provider inside of Florida Blue's service area, as described <br />elsewhere in this Agreement. This may occur where the Host Blue's corresponding <br />payment would be more than Florida Blue's in-service area nonparticipati ng provider <br />payment. Florida Blue may choose to negotiate a pay ment with such a provider on <br />an exception basis. <br />Unless otherwise stated, in any of these exception situations, the member may be <br />responsible for the difference between the amount that the nonparticipating <br />healthcare provider bills and the payment Florida Blue will make for the covered <br />services as set forth in this paragraph. <br />2. Fees and Compensation <br />Employer understands and agrees to reim burse Florida Blue for certain fees and <br />compensation which we are obligated under applicabl a Inter -Plan Arrangement <br />requirements to pay to the Host Blues, to the Association and/or to vendors of Inter -Plan <br />Arrangement -related services. The specific fees and compensation that are charged to <br />Employer are set forth in Exhibit B, if applicable. Fees and compensation under <br />applicable Inter -Plan Arrangements may be revised from time to time. <br />G. BlueCard Worldwide(D Program <br />1. General Information <br />If members are outside the United States, (the Commonwealth of Puerto Rico and the <br />U.S. Virgin Islands) (hereinafter: "BlueCard service area"), they may be able to take <br />advantage of the BlueCard Worldwide Program when accessing covered healthcare <br />services. The BlueCard Worldwide Program is unlike the BlueCard Program available <br />in the BlueCard service area in certain ways. For instance, although the BlueCard <br />Worldwide Program assists members with accessing a network of inpatient, outpatient <br />and professional providers, the network is not served by a Host Blue. As such, when <br />members receive care from providers outside the BlueCard service area, the members <br />will typically have to pay the providers and subm it the claims themselves to obtain <br />reimbursement for these services. <br />• Inpatient Services <br />In most cases, if members contact the BlueCard Worldwide Service Center for <br />assistance, hospitals will not require members to pay for covered inpatient services, <br />except for their cost -share amounts. In such cases, the hospital will submit member <br />claims to the BlueCard Worldwide Service Center to initiate claims processing. <br />20160629 <br />7 <br />
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