The eligibility and enrollment rules for the U

Retiree Health Care SPD Effective January 1, 2012
Allowed Amounts
To make sure the fees charged by providers are not excessive, BCBS pays based on “allowed
amounts.” The allowed amount is the negotiated amount of payment that a participating provider
has agreed to accept as payment in full (less deductibles, coinsurance and copayments) for a
covered service at the time a claim is processed. All Program payments are based on the allowed
amount. The allowed amount may vary from one provider to another for the same service. Also,
BCBS may periodically adjust the allowed amount.
If participating providers charge more than the allowed amount, the difference will appear in the
provider reduction column on your Explanation of Benefits (the statement sent from BCBS
following a claim). Except for certain locations and for non-covered services, you should not be
billed for any amounts exceeding allowed amounts when you use participating providers. Refer
to the “Which Network Providers to Use” section of this SPD for more information.. If you are
so billed, do not pay the invoice. Check with your health care provider or the BCBS customer
service department.
When you obtain health care services through the BlueCard Program outside the geographic area
BCBS of MN serves, the amount you pay for covered services is usually calculated on the lower
of:
1. The billed charges for your covered services; or
2. The negotiated price that the on-site Blue Cross and/or Blue Shield Plan (“Host Blue”) passes
on to the Claims Administrator.
Often, this “negotiated price” consists of a simple discount that reflects the actual price paid by
the Host Blue. Sometimes, however, the negotiated price is either 1) an estimated price that
factors expected settlements, withholds, any other contingent payment arrangements and nonclaims
transactions with your health care provider or with a specified group of providers into the
actual price; or 2) billed charges reduced to reflect an average expected savings with your health
care provider or with a specified group of providers. The price that reflects average savings may
result in greater variation (more or less) from the actual price paid than will the estimated price.
The negotiated price will be prospectively adjusted to correct for over- or underestimation of past
prices. The amount you pay, however, is considered a final price and will not be affected by the
prospective adjustment.
Statutes in a small number of states may require the Host Blue either 1) to use a basis for
calculating your liability for covered services that does not reflect the entire savings realized or
expected to be realized on a particular claim; or 2) to add a surcharge. If any state statutes
mandate liability calculation methods that differ from the usual BlueCard method noted above or
require a surcharge, the Claims Administrator will calculate your liability for any covered health
care services according to the applicable state statute in effect at the time you received your care.
Regardless of the plan you are enrolled in, if you obtain care from a non-participating
provider, you are responsible for paying the difference between the billed charge and the
allowed amount if your provider charges more than the allowed amount. The additional
cost would depend on what your physician charges. For expensive procedures, this amount
could be significant. Also, this excess amount will not apply to the deductible or out-ofpocket
maximum.
48