Anthem Blue Cross Blue Shield PPO Plan - Teamworks at Home ...

services described in this SPD� Out-of-network
providers are not obligated to:
• Accept payment based on the allowed amount�
• File claims for you�
For benefts information on these providers, refer to the
“Benefts charts” starting on page 10�
Charges that are your responsibility
When you use BlueCard PPO providers for covered
services, payment is based on the allowed amount as
determined by Anthem BCBS� You are not required to
pay for charges that exceed the allowed amount� You
are required to pay the following amounts:
• Deductibles
• Coinsurance
• Charges that exceed the beneft maximum
• Charges for services that are not covered
When you use out-of-network participating providers
for covered services, payment is still based on the
allowed amount as determined by Anthem BCBS� Most
out-of-network participating providers agree to accept
the allowed amount as payment in full� If not, you are
required to pay all charges that exceed the allowed
amount� In addition, you are required to pay the
following amounts:
• Deductibles
• Coinsurance
• Charges that exceed the maximum beneft level
• Charges for services that are not covered
When you use out-of-network nonparticipating
providers for covered services, payment is still based on
the allowed amount as determined by Anthem BCBS�
However, because an out-of-network nonparticipating
provider has not entered into a service agreement
with the local Blue Cross Blue Shield organization,
that provider is not obligated to accept the allowed
amount as payment in full� This means that you may
have substantial out-of-pocket expenses when you
use an out-of-network nonparticipating provider�
The diference between the out-of-network provider’s
charges and the allowed amount is not applied toward
the deductible, coinsurance amounts, or out-of-pocket
maximum and is your responsibility� This applies to all
out-of-network services described in this SPD�
You are required to pay the following amounts:
• Charges that exceed the allowed amount
• Deductibles
• Coinsurance
6
• Charges that exceed the beneft maximum level
• Charges for services that are not covered, including
services that Anthem BCBS, in its full discretion,
determines are not covered based on claims coding
and coverage guidelines
When you obtain health care services through the
BlueCard Program outside the geographic area Anthem
BCBS serves, the amount you pay for covered services
is usually calculated on the lower of either:
• The billed charges for your covered services
• The negotiated price that the local Blue Cross Blue
Shield organization (“Host Blue”) passes on to
Anthem BCBS
Often, this “negotiated price” consists of a simple
discount that refects 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 specifed group of
providers into the actual price; or (2) billed charges
reduced to refect an average expected savings with
your health care provider or with a specifed group of
providers� The price that refects 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 overor
underestimation of past prices� The amount you
pay, however, is considered a fnal price and will not be
afected by the prospective adjustment�
Statutes in a small number of states may require the
Host Blue to either (1) use a basis for calculating your
liability for covered services that does not refect the
entire savings realized or expected to be realized
on a particular claim; or (2) add a surcharge� If any
state statutes mandate liability calculation methods
that difer from the usual BlueCard Program method
noted above or require a surcharge, Anthem BCBS
will calculate your liability for any covered health care
services according to the applicable state statute in
efect at the time you received your care�
Recommendations by health care providers
In some cases, your provider may recommend or provide
written authorization for services that are specifcally
excluded by the Plan� When these services are referred
or recommended, a written authorization from your
provider does not override any specifc Plan exclusions�
Time periods
When determining benefts, and when coverage
starts and ends, a day begins at 12:00 a�m� and ends at
11:59 p�m�
Anthem Blue Cross Blue Shield PPO Plan