3/27/2018 3:17:35 PM
8/30/2017 4:19:51 PM
Official Document Type
Agenda Item Number
Blue Cross and Blue Shield of Florida
Administrative Services Agreement
Group Health Plan
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When the Administrator is charged an access fee, the Administrator will pass the <br />charge along to the Employer as a claims expense. If the Administrator receives <br />an access fee credit, the Administrator will give the Employer a claims expense <br />credit. Access fees are considered a claims expense because they represent claim <br />dollars the Administrator was unable to, or in the case of a credit was able to, <br />avoid. <br />Instances may occur in which the Administrator does not pay a claim (or pays <br />only a small amount) because the amounts eligible for payment were applied to <br />the Deductible, Coinsurance or Copayment. In such instances the Host Plan's <br />arrangement with its Provider may allow the negotiated payment rate to apply <br />when the amount is fully or mostly a patient obligation. If so, the Administrator <br />will pay the Host Plan's access fee and pass it along to the Employer as a claims <br />expense even though the Administrator paid little or none of the claim. <br />The negotiated rate paid by the Administrator to the Host Plan under the BlueCard <br />Program for health care services will be arrived at using one of the following three <br />options. The first option uses the actual price paid on the claim. In limited <br />circumstances this price may be greater than charges (e.g. sometimes payment <br />under a DRG payment system will be greater than charges). The second option <br />uses an estimated price. This price reflects an adjusted aggregate payment <br />expected to result from past or future settlements or other non -claims transactions <br />with all of the Host Plan's Health Care Providers or one or more particular <br />Providers. The third option uses a discount from billed charges. This price is <br />obtained by applying an average savings factor representing the Host Plan's <br />expected savings for all of its Providers or for a specific group of Providers. <br />Estimated and average pricing used under options two and three may be <br />prospectively adjusted. This helps correct for either over or under estimation of <br />past prices. <br />Additionally, the following charges will be paid for each claim processed under <br />the BlueCard Program as an administrative fee under this Agreement: inpatient <br />claims - $11; outpatient claims - $11; and professional claims - $5, these charges <br />being subject to change without further notification to the Employer. <br />The calculation of Coinsurance and other member liability for Covered Services <br />will be at the lower of the Provider's billed charges or the negotiated rate the <br />Administrator pays the Host Plan under the BlueCard Program. Also note that <br />statutes in a small number of states require local Blue Cross and/or Blue Shield <br />Plans to use a basis for calculating member liability for Covered Services that <br />does not reflect the entire savings realized or expected to be realized on a <br />
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