2023 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 4. Your Costs for Covered Services
Differences between our allowance and the bill
Section 4. Your Costs for Covered Services
Differences between our allowance and the bill
Differences between our allowance and the bill
Our “Plan allowance” is the amount we use to calculate our payment for certain types of covered services. Fee-for-service plans arrive at their allowances in different ways, so allowances vary. For information about how we determine our Plan allowance, see the definition of Plan allowance in Section 10.
Often, the provider’s bill is more than a fee-for-service Plan’s allowance. It is possible for a provider’s bill to exceed the Plan’s allowance by a significant amount. Whether or not you have to pay the difference between our allowance and the bill will depend on the type of provider you use. Providers that have agreements with this Plan are Preferred and will not bill you for any balances that are in excess of our allowance for covered services. See the descriptions appearing below for the types of providers available in this Plan.
Remember, you must use Preferred providers in order to receive benefits. See page 18 for the exceptions to this requirement.
Our “Plan allowance” is the amount we use to calculate our payment for certain types of covered services. Fee-for-service plans arrive at their allowances in different ways, so allowances vary. For information about how we determine our Plan allowance, see the definition of Plan allowance in Section 10.
Often, the provider’s bill is more than a fee-for-service Plan’s allowance. It is possible for a provider’s bill to exceed the Plan’s allowance by a significant amount. Whether or not you have to pay the difference between our allowance and the bill will depend on the type of provider you use. Providers that have agreements with this Plan are Preferred and will not bill you for any balances that are in excess of our allowance for covered services. See the descriptions appearing below for the types of providers available in this Plan.
- Preferred providers. These types of providers have agreements with the Local Plan to limit what they bill our members. Because of that, when you use a Preferred provider, your share of the provider’s bill for covered care is limited.
Your share consists only of your deductible, coinsurance, and/or copayment. Here is an example about coinsurance: You see a Preferred physician who charges $250, but our allowance is $100. If you have met your deductible, you are only responsible for your coinsurance. That is, you pay just 30% of our $100 allowance ($30). Because of the agreement, your Preferred physician will not bill you for the $150 difference between our allowance and his/her bill.
Remember, you must use Preferred providers in order to receive benefits. See page 18 for the exceptions to this requirement.
- Non-preferred Providers:
- Participating provider/Member facility. There are no benefits for care performed by Participating providers; you pay all charges. See page 18 for the exceptions to this requirement.
- Non-participating providers/Non-member facility. There are no benefits for care performed by Non-participating providers; you pay all charges. See page 18 for the exceptions to this requirement.
You should also see section Important Notice About Surprise Billing – Know Your Rights below that describes your protections against surprise billing under the No Surprises Act.
- Participating provider/Member facility. There are no benefits for care performed by Participating providers; you pay all charges. See page 18 for the exceptions to this requirement.