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1996-242 (2)
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1996-242 (2)
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Last modified
3/27/2018 3:16:42 PM
Creation date
9/1/2017 2:29:52 PM
Metadata
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Template:
Official Documents
Official Document Type
Agreement
Approved Date
01/01/2012
Control Number
1996-242
Entity Name
Blue Cross and Blue Shield of Florida, Inc.
Subject
Group Health Plan
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provider pricing agreements or any other information which is of a <br />confidential or proprietary nature, as determined by the Administrator. <br />3.7 Claims Payments <br />The source or sources of payment under the Group Health Plan are to be <br />only the assets of the Employer, and the Administrator will have no liability <br />whatsoever for providing a source from which payments will be made under <br />the Health Care Plan. <br />3.8 Claims Payments Outside the State of Florida <br />When amounts are paid or payable by the Administrator to providers of <br />services outside the state of Florida under this Agreement and the Group <br />Health Plan, reimbursement to the out-of-state provider and the insured's <br />financial responsibilities (e.g. coinsurance requirement limits) may be <br />determined based upon the provider arrangements, if any, the Blue Cross <br />and/or Blue Shield (herein "BCBS") Plan in the area where services are <br />provided has with its providers. The Administrator will coordinate with the <br />appropriate BCBS Plan when reimbursement and financial responsibilities <br />are to be handled under these special programs. Participation in such <br />programs allows the Administrator to make available out -of -area services at <br />rates that would generally not be available had BCBSF paid the provider <br />directly. <br />Under these programs, when an out-of-state BCBS Plan reports its provider <br />payments to the Administrator, it may either report the actual payment or an <br />average payment calculated according to a method approved by the <br />Administrator and/or by the Blue Cross and Blue Shield Association, an <br />association of independent Blue Cross and/or Blue Shield Plans. The <br />payments may sometimes be greater than charges. Additionally, each such <br />BCBS Pian may charge an access fee, which will be added to the claim <br />charge from such Plan. Such access fee will generally not exceed 10 <br />percent (or $2000 for any claim) of the discount/differential savings which <br />result from the BCBS Plans' health care provider network agreements. The <br />total amount paid by the Administrator to such other Plans shall be <br />considered the amount of the claim under this Agreement and shall be the <br />financial responsibility of the Employer. <br />Additionally, the following charges, will be paid for each claim processed <br />under these special programs. These charges will be paid out of the <br />Employer's Administrative Fee which is set forth in the Agreement. <br />960904.1 <br />!4' <br />6 <br />23z <br />
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