2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 10. Definitions of Terms We Use in This Brochure
Page 157
Section 10. Definitions of Terms We Use in This Brochure
Page 157
- For outpatient services resulting from a medical emergency or accidental injury that are billed by Non-member facilities, our allowance is the lesser of the billed amount or the qualifying payment amount (QPA) determined in accordance with federal laws and regulations (minus any amount for noncovered services);
- For non-emergency medical services performed in Preferred hospitals provided by physicians and other covered healthcare professionals identified under the NSA (see page 32) that do not contract with your local Blue Cross and Blue Shield Plan and cannot balance bill you under this regulation, our allowance is equal to the lesser of the billed amount or the qualifying payment amount (QPA) determined in accordance with federal laws and regulations;
- For physicians and other covered healthcare professionals that do not contract with your local Blue Cross and Blue Shield Plan, our allowance is equal to the greater of (1) the Medicare participating fee schedule amount or the Medicare Part B Drug Average Sale Price (ASP) for the service, drug, or supply in the geographic area in which it was performed or obtained or (2) 100% of the Local Plan Allowance. In the absence of a Medicare participating fee schedule amount or ASP for any service, drug, or supply, our allowance is the Local Plan Allowance. Contact your Local Plan if you need more information. We may refer to our allowance for Non-participating providers as the “NPA” (for “Non-participating Provider Allowance”);
- For emergency medical services performed in the emergency department of a hospital provided by physicians and other covered healthcare professionals, and air ambulance providers that do not contract with your local Blue Cross and Blue Shield Plan, our allowance is the lesser of the billed amount or the qualifying payment amount (QPA) determined in accordance with federal laws and regulations;
- For prescription drugs furnished by retail pharmacies that do not contract with CVS Caremark, our allowance is the average wholesale price (“AWP”) of a drug on the date it is dispensed, as set forth by Medi-Span in its national drug data file; and
- For services you receive outside of the United States, Puerto Rico, and the U.S. Virgin Islands from providers that do not contract with us or with the Overseas Assistance Center (provided by GMMI), we use our Overseas Fee Schedule to determine our allowance. Our fee schedule is based on a percentage of the amounts we allow for Non-participating providers in the Washington, D.C., area, or a customary percent of billed charge, whichever is higher.
Important notice about Non-participating providers!
Note: Using Non-participating or Non-member providers could result in your having to pay significantly greater amounts for the services you receive. Non-participating and Non-member providers are under no obligation to accept our allowance as payment in full. If you use Non-participating and/or Non-member providers, you will be responsible for any difference between our payment and the billed amount (except in certain circumstances involving covered Non-participating professional care – see below). In addition, you will be responsible for any applicable deductible, coinsurance, or copayment. You can reduce your out-of-pocket expenses by using Preferred providers whenever possible. To locate a Preferred provider, visit www.fepblue.org/provider to use our National Doctor & Hospital Finder, or call us at the customer service phone number on the back of your ID card. We encourage you to always use Preferred providers for your care.
Note: For certain covered services from Non-participating professional providers, your responsibility for the difference between the Non-participating Provider Allowance (NPA) and the billed amount may be limited. See page 32.
For more information, see Differences between our allowance and the bill in Section 4. For more information about how we pay providers overseas, see pages 32 and 130.
Post-service claims
Any claims that are not pre-service claims. In other words, post-service claims are those claims where treatment has been performed and the claims have been sent to us in order to apply for benefits.
Precertification
The requirement to contact the local Blue Cross and Blue Shield Plan serving the area where the services will be performed before being admitted for inpatient care. Please refer to the precertification information listed in Section 3.