ii. an estimated price. An estimated price is a negotiated payment reduced or increased by a
percentage to take into account certain payments negotiated with the Provider and other
Claim- and non-Claim-related transactions. Such transactions may include, but are not limited
to, anti-fraud and abuse recoveries, Provider refunds not applied on a Claim-specific basis,
retrospective settlements, and performance-related bonuses or incentives, or
iii. an average price. An average price is a percentage of Billed Charges representing the
aggregate payments negotiated by the Host Blue with all of its health care Providers or a
similar classification of its Providers and other Claim- and non-Claim-related transactions. Such
transactions may include the same ones as noted above for an estimated price.
Host Blues using either an estimated price or an average price may, in accordance with Inter-Plan
Programs policies, prospectively increase or reduce such prices to correct for over- or
underestimation of past prices (i.e., prospective adjustments may mean that a current price
reflects additional amounts or credits for Claims already paid to Providers or anticipated to be paid
to or received from Providers). However, the amount paid by the Member and Employer is a final
price; no future price adjustment will result in increases or decreases to the pricing of past Claims.
The BlueCard Program requires that the price submitted by a Host Blue to Anthem is a final price
irrespective of any future adjustments based on the use of estimated or average pricing. If a Host
Blue uses either an estimated price or an average price on a Claim, it may also hald some portion
of the amount that Employer pays in a variance account, pending settlement with its Network
Providers. Because all amounts paid are final, neither variance account funds held to be paid, nor
the funds expected to be received, are due to or from Employer. Such payable or receivable
would be eventually exhausted by health care Provider settlements and/or through prospective
adjustment to the negotiated prices. Some Host Blues may retain interest earned, if any, on funds
held in variance accounts.
A small number of states require Host Blues either (i) to use a basis for determining Member
liability for Covered Services that does not reflect the entire savings realized, or expected to be
realized, on a particular Claim, or (ii) to add a surcharge. Should the state in which health care
services are accessed mandate liability calculation methods that differ from the negotiated price
methodology or require a surcharge, Anthem would then calculate Member liability and Employer
liability in accordance with applicable law.
2. Return of Overpayments. Under the BlueCard Program, recoveries from a Host Blue or its
Network Providers can arise in several ways, including, but not limited to, anti-fraud and abuse
recoveries, health care Provider/hospital audits, credit balance audits, utilization review refunds,
and unsolicited refunds. In some cases, the Host Blue will engage a third party to assist in
identification or collection of recovery amounts. The fees of such a third party may be netted
against the recovery. Recovery amounts determined in this way will be applied in accordance with
applicable Inter-Plan Programs policies, which generally require correction on a Claim-by-Claim or
prospective basis.
c. Negotiated National Account Arrangements. As an alternative to the BlueCard Program, Member Claims
for Covered Services may be processed through a negotiated National Account arrangement with a Host
Blue. For purposes of this Article, a "National Account" is an Employer that has membership in more than
one state.
lf Anthem and Emplover have agreed that (a) Host Blue(s) shall make available a custom health care
Provider network(s) in connection with this Agreement, then the terms and conditions set forth in Anthem's
negotiated National Account arrangement(s) with such Host Blue(s) shall apply. In negotiating such
arrangement(s), Anthem is not acting on behalf of or as an agent for Employer, the Plan or Members.
Employer agrees that Anthem will not have any responsibility in connection with the processing and
payment of Claims when Members access such network(s), except as may be set forth in the relevant
participation agreement.
Member Liability Calculation. Member liability calculation will be based on the lower of either Billed
Charges or negotiated price made available to Anthem by the Host Blue that allows Members access to
negotiated participation agreement networks of specified Network Providers outside of Anthem’s service
area,
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City of Nashua 06/17/2013
