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2018-170
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Last modified
1/4/2021 11:21:35 AM
Creation date
9/19/2018 1:21:19 PM
Metadata
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Template:
Official Documents
Official Document Type
Agreement
Approved Date
09/11/2018
Control Number
2018-170
Agenda Item Number
8.AA.
Entity Name
Blue Cross and Blue Shield of Florida, Inc.
Florida Blue
Subject
Blue Medicare Advantage Plan Renewal
BlueMedicare Master Agreement
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healthcare services outside the geographic area we serve, the claim for those services will be processed <br />through the Inter -Plan Medicare Advantage Program. The Inter -Plan Medicare Advantage Program <br />available to members under this agreement is described generally below. <br />B. Member Liability Calculation <br />When you receive Covered Services outside of our service area from a Medicare Advantage PPO network <br />provider, the cost of the service, on which member liability (copayment/coinsurance) is based, will be <br />either: <br />• The Medicare allowable amount for covered services; or <br />• The amount either we negotiate with the provider or the Host Blue negotiates with its provider on <br />behalf of our members, if applicable. The amount negotiated may be either higher than, lower than, <br />or equal to the Medicare allowable amount. <br />C. Nonparticipating Healthcare Providers Outside Our Service Area <br />When Covered Services are provided outside of our service area by nonparticipating healthcare providers, <br />the amount(s) a member pays for such services will be based on either the payment arrangements, <br />described above, for Medicare Advantage PPO network providers, Medicare's limiting charge where <br />applicable or the provider's billed charge. In these situations, the member may be responsible for the <br />difference between the amount that the nonparticipating healthcare provider bills and the payment we will <br />make for the covered services as set forth in this paragraph. Payments for out -of -network emergency <br />services will be governed by applicable federal and state law. <br />SECTION 7: GENERAL PROVISIONS <br />A. Administration and Record Retention <br />You must provide us with any information we need to administer the coverage and/or benefits to be <br />provided or needed to compute the Premium due. While this coverage is in force, we have the right, at <br />any reasonable time, to examine your records on any issues necessary to verify information provided by <br />you. You must retain all records relating to this Agreement, including but not limited to those relating to <br />LIS administration, for the current calendar year plus an additional ten (10) years. <br />B. Assignment and Delegation <br />You may not assign, delegate or otherwise transfer this Agreement and the obligations hereunder without <br />our written consent. Any assignment, delegation, or transfer made in violation of this provision shall be <br />void. We may assign, delegate, or otherwise transfer this Agreement to our successor in interest or an <br />affiliated entity without your consent at any time. <br />C. Authorization <br />Where this Agreement requires that an act involving the administration of coverage and/or benefits be <br />authorized or approved by us, such authorization or approval shall be considered given when provided in <br />writing by a duly authorized officer of Florida Blue or his or her designee. <br />
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