2011-2012 Full Benefits Summary - Office of Student Health Benefits

Out-of-Network ProvidersOut-of-Network Participating ProvidersWhen you use Out-of-Network Participating Providers for covered services, payment is still based on the allowedamount. Most Out-of-Network Participating Providers accept the Claims Administrator’s payment based on theallowed amount. However, contact your Out-of-Network Participating Provider to verify if they accept the ClaimsAdministrator’s payment based on the allowed amount (to determine if you will have additional financial liability).In addition you are required to pay the following amounts:1. charges that exceed the allowed amount if the Out-of-Network Participating Provider does not accept theClaims Administrator’s payment based on the allowed amount;2. copays and coinsurance;3. charges that exceed the benefit maximum;4. charges for services that are not covered; and5. charges for services that are investigative or not medically necessary if you are notified in writing before youreceive services that the services are not covered and you agree in writing to pay all charges.Nonparticipating ProvidersWhen you use Nonparticipating Providers for covered services, payment is still based on the allowed amount.However, because a Nonparticipating Provider has not entered into a network contract with the ClaimsAdministrator or the local Blue Cross and/or Blue Shield Plan, the Nonparticipating Provider is not obligated toaccept the allowed amount as payment in full. This means that you may have substantial out-of-pocket expensewhen you use a Nonparticipating Provider. You are required to pay the following amounts:1. charges that exceed the allowed amount;2. copays and coinsurance;3. charges that exceed the benefit maximum;4. charges for services that are not covered; including services that we determine are not covered based onclaims coding guidelines; and5. charges for services that are investigative or not medically necessary.Inter-Plan ProgramsOut-of-Area ServicesThe Claims Administrator has a variety of relationships with other Blue Cross and/or Blue Shield Licenseesreferred to generally as “Inter-Plan Programs.” Whenever you obtain health care services outside of the ClaimsAdministrator’s service area, the claims for these services may be processed through one of these Inter-PlanPrograms, which include the BlueCard Program and may include negotiated National Account arrangementsavailable between the Claims Administrator and other Blue Cross and Blue Shield Licensees.Typically, when accessing care outside the Claims Administrator’s service area, you will obtain care from healthcare providers that have a contractual agreement (i.e., are “participating providers”) with the local Blue Crossand/or Blue Shield Licensee in that other geographic area (“Host Blue”). In some instances, you may obtain carefrom Nonparticipating Providers. The Claims Administrator’s payment practices in both instances are describedbelow.17