Page 76 - Aegion PPO SPDs
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CLAIMS PAYMENT
Network Providers have agreed to submit claims directly to the local Blue Cross and/or Blue Shield plan in
their area. Therefore, if the Network Hospitals, Physicians and ancillary Providers are used, claims for their
services will generally not have to be filed by the Member. In addition, many Out-of-Network Hospitals and
Physicians will also file claims if the information on the Blue Cross and Blue Shield Identification Card is
provided to them. If the Provider requests a claim form to file a claim, a claim form can be obtained by
contacting Your local Human Resources Department or by visiting www.anthem.com.
How to Obtain Benefits
When You receive Covered Services from a Network Physician or other Network licensed health care
provider, ask him or her to complete a claim form. Payment for Covered Services will be made directly to
the provider.
Under normal conditions, the Claims Administrator should receive the proper claim form within 12 months
after the service was provided.
Each person enrolled through the Plan receives an Identification Card. Remember, in order to receive full
benefits, You must receive treatment from a Network Provider. When admitted to a Network Hospital,
present Your Identification Card. Upon discharge, You will be billed only for those charges not covered by
the Plan. Residents of Missouri must use POS Network Providers.
For services received from a Non-Network Provider, You are responsible for making sure a claim is filed in
order to receive benefits. Many Hospitals, Physicians, and other Providers, who are Non-Network
Providers, will submit Your claim for You. If You submit the claim use a claim form.
How Benefits Are Paid
Maximum Allowed Amount
General
This section describes how the Claims Administrator determines the amount of reimbursement for Covered
Services. Reimbursement for services rendered by Network and Out-of-Network Providers is based on this
Plan’s Maximum Allowed Amount for the Covered Service that You receive. Please see the “Inter-Plan
Arrangements” section for additional information.
The Maximum Allowed Amount for this Plan is the maximum amount of reimbursement the Plan will allow
for services and supplies:
that meet the Plan’s definition of Covered Services, to the extent such services and supplies are
covered under Your Plan and are not excluded;
that are Medically Necessary; and
that are provided in accordance with all applicable preauthorization, utilization management or other
requirements set forth in Your Plan.
You will be required to pay a portion of the Maximum Allowed Amount to the extent You have not met Your
Deductible or have Coinsurance. In addition, when You receive Covered Services from an Out-of-Network
Provider, You may be responsible for paying any difference between the Maximum Allowed Amount and
the Provider’s actual charges. This amount can be significant.
When You receive Covered Services from a Provider, the Claims Administrator will, to the extent applicable,
apply claim processing rules to the claim submitted for those Covered Services. These rules evaluate the
claim information and, among other things, determine the accuracy and appropriateness of the procedure
and diagnosis codes included in the claim. Applying these rules may affect the Claims Administrator’s
determination of the Maximum Allowed Amount. The Claims Administrator’s application of these rules does
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Network Providers have agreed to submit claims directly to the local Blue Cross and/or Blue Shield plan in
their area. Therefore, if the Network Hospitals, Physicians and ancillary Providers are used, claims for their
services will generally not have to be filed by the Member. In addition, many Out-of-Network Hospitals and
Physicians will also file claims if the information on the Blue Cross and Blue Shield Identification Card is
provided to them. If the Provider requests a claim form to file a claim, a claim form can be obtained by
contacting Your local Human Resources Department or by visiting www.anthem.com.
How to Obtain Benefits
When You receive Covered Services from a Network Physician or other Network licensed health care
provider, ask him or her to complete a claim form. Payment for Covered Services will be made directly to
the provider.
Under normal conditions, the Claims Administrator should receive the proper claim form within 12 months
after the service was provided.
Each person enrolled through the Plan receives an Identification Card. Remember, in order to receive full
benefits, You must receive treatment from a Network Provider. When admitted to a Network Hospital,
present Your Identification Card. Upon discharge, You will be billed only for those charges not covered by
the Plan. Residents of Missouri must use POS Network Providers.
For services received from a Non-Network Provider, You are responsible for making sure a claim is filed in
order to receive benefits. Many Hospitals, Physicians, and other Providers, who are Non-Network
Providers, will submit Your claim for You. If You submit the claim use a claim form.
How Benefits Are Paid
Maximum Allowed Amount
General
This section describes how the Claims Administrator determines the amount of reimbursement for Covered
Services. Reimbursement for services rendered by Network and Out-of-Network Providers is based on this
Plan’s Maximum Allowed Amount for the Covered Service that You receive. Please see the “Inter-Plan
Arrangements” section for additional information.
The Maximum Allowed Amount for this Plan is the maximum amount of reimbursement the Plan will allow
for services and supplies:
that meet the Plan’s definition of Covered Services, to the extent such services and supplies are
covered under Your Plan and are not excluded;
that are Medically Necessary; and
that are provided in accordance with all applicable preauthorization, utilization management or other
requirements set forth in Your Plan.
You will be required to pay a portion of the Maximum Allowed Amount to the extent You have not met Your
Deductible or have Coinsurance. In addition, when You receive Covered Services from an Out-of-Network
Provider, You may be responsible for paying any difference between the Maximum Allowed Amount and
the Provider’s actual charges. This amount can be significant.
When You receive Covered Services from a Provider, the Claims Administrator will, to the extent applicable,
apply claim processing rules to the claim submitted for those Covered Services. These rules evaluate the
claim information and, among other things, determine the accuracy and appropriateness of the procedure
and diagnosis codes included in the claim. Applying these rules may affect the Claims Administrator’s
determination of the Maximum Allowed Amount. The Claims Administrator’s application of these rules does
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