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2023-098B
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Last modified
3/18/2024 12:03:39 PM
Creation date
3/18/2024 11:53:00 AM
Metadata
Fields
Template:
Official Documents
Official Document Type
Agreement
Approved Date
05/16/2023
Control Number
2023-098B
Agenda Item Number
12.D.2.
Entity Name
Blue Cross and Blue Shield
Subject
Shield Transition Health Plan Administrative Services from
Blue Cross Shield of Florida Inc.(Florida Blue)
to Blue Cross Blue Shield National Alliance effective 10/01/2023 thru 9/30/2026
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In some exception cases, at Employer's direction, BCBSF and/or its Designated <br />Agent may pay claims from nonparticipating healthcare providers outside of <br />BCBSF's Designated Agent's service area (i.e., South Carolina) based on the <br />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 BCBSF <br />and/or its Designated Agent in BCBSF's and/or its Designated Agent's sole and <br />absolute discretion, or by applicable state law. In other exception cases, at <br />Employer's direction, BCBSF and/or its Designated Agent may pay such claims <br />based on the payment BCBSF and/ or its Designated Agent would make if BCBSF <br />and/or its Designated Agent were paying a nonparticipating provider inside <br />BCBSF's Designated Agent's service area (i.e. South Carolina), as described <br />elsewhere in this Agreement. This may occur where the Host Blue's corresponding <br />payment would be more than BCBSF's Designated Agent's in-service area <br />nonparticipating provider payment. BCBSF and/or its Designated Agent may <br />choose to negotiate a payment with such a provider on an exception basis. <br />The member may be responsible for the difference between the amount that the <br />nonparticipating healthcare provider bills and the payment BCBSF and/or its <br />Designated Agent will make for the covered services as set forth in this paragraph. <br />2. Fees and Compensation <br />Employer understands and agrees to reimburse BCBSF and/or its Designated Agent <br />for certain fees and compensation which we are obligated under applicable Inter -Plan <br />Arrangement requirements to pay to the Host Blues, to the Association and/or to <br />vendors of Inter -Plan Arrangement related services. The specific fees and <br />compensation that are charged to Employer are set forth in this Exhibit B, if <br />applicable. Fees and compensation under applicable Inter -Plan Arrangements may be <br />revised from time to time. <br />G. Blue Cross Blue Shield Global® Core <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 Blue Cross Blue Shield Global® Core when accessing covered <br />healthcare services. The Blue Cross Blue Shield Global® Core is unlike the B1ueCard <br />Program available in the B1ueCard service area in certain ways. For instance, although <br />the Blue Cross Blue Shield Global® Core assists members with accessing a network <br />of inpatient, outpatient and professional providers, the network is not served by a Host <br />Blue. As such, when members receive care from providers outside the B1ueCard <br />service area, the members will typically have to pay the providers and submit the <br />claims themselves to obtain reimbursement for these services. <br />• Inpatient Services <br />In most cases, if members contact the Blue Cross Blue Shield Global® Core <br />Service Center for assistance, hospitals will not require members to pay for <br />covered inpatient services, except for their cost -share amounts. In such cases, the <br />hospital will submit member claims to the Blue Cross Blue Shield Global® Core <br />35 <br />
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