d, Non-Network Providers Outside Anthem's Service Area.
1. Member Liability Calculation. When Covered Services are provided outside of Anthem's service
area by non-Network Providers, the amount a Member pays for such services will generally be
based on either the Host Blue's non-Network Provider local payment or the pricing arrangements
required by applicable state law. In these situations, the Member may be responsible for the
difference between the amount that the Non-Network Provider bills and the payment Anthem will
make for the Covered Services as set forth in this paragraph.
2. Exceptions. In some exception cases, Anthem may pay Claims from non-Network Providers
outside of Anthem's service area based on the Provider's Billed Charges, such as in situations,
where a Member did not have reasonable access to a Network Provider, as determined by
Anthem in Anthem'’s sole and absolute discretion or by applicable state law. In other exception
cases, Anthem may pay such a Claim based on the payment it would make if Anthem were paying
a non-Network Provider inside of Anthem's service area, as described elsewhere in this
Agreement, where the Host Blue's corresponding payment would be more than Anthem's in-
service area non-Network Provider payment, or in its sole and absolute discretion, Anthem may
negotiate a payment with such a Provider on an exception basis. In any of these exception
situations, the Member may be responsible for the difference between the amount that the non-
Network Provider bills and the payment Anthem will make for the Covered Services as set forth in
this paragraph.
e. Inter-Plan Program Fees and Compensation. Employer understands and agrees to reimburse Anthem for
certain fees and compensation which it is obligated under BlueCard or any other Inter-Plan Program, to pay
to the Host Blues, to the BCBSA, and/or to BlueCard or Inter-Plan Program vendors, as described below.
Fees and compensation under BlueCard and other Inter-Plan Programs may be revised in accordance with
the specific Program's standard procedures for revising such fees and compensation, which do not provide
for prior approval by any groups. Such revisions typically are made annually as a result of Program policy
changes and/or vendor negotiations. These revisions may occur at any time during the course of a given
calendar year, and they do not necessarily coincide with the Agreement Period. With respect to Negotiated
National Account Arrangements, the participation with the Host Blue may provide that Anthem must pay an
administrative and/or network access fee to the Host Blue. For this type of negotiated participation
arrangement, any such administrative and/or network access fee will not be greater than the comparable
fees that would be charged under the BlueCard Program. Anthem will charge these fees as described in
Section 7 of Schedule A.
ARTICLE 16 - CLAIMS LITIGATION
a. Anthem shall defend against any legal action or proceeding brought against Anthem to recover a claim for
benefits under the Plan as administered by Anthem. If a demand for benefits under the Plan is asserted, or
litigation, investigation, or other proceedings are commenced against Anthem by a Member, or by any other
party on behalf of a Member, in connection with the Plan, Anthem shall provide notice to Employer as soon
as practicable. Anthem will select and retain counsel. Except as otherwise provided in Article 16(b),
Employer will assume liability for payment of attorneys’ fees and costs in connection with the litigation,
proceeding, or investigation. If Employer or Plan are also named in the legal action or proceeding,
Employer reserves the right to retain separate counsel for itself, in its sole discretion and at its own
expense, and separate counsel for the Plan. If during such litigation, investigation or proceedings Employer
and Anthem are both represented by the same counsel selected by Anthem and a conflict of interest arises,
the selected counsel shall continue to represent Anthem's interests. Employer shall waive any conflict for
such representation and retain its own counsel, or separate counsel for the Plan, at its own expense. Each
Party will provide the other with reasonable cooperation in the defense of any such matter. Anthem is
authorized to settle or compromise any claim to recover benefits under the Plan arising out of a course of
legal action with the approval of Employer, which approval shall not be unreasonably withheld.
b. Notwithstanding the above in this Article 16, if Anthem fails to perform its responsibility to review and
determine Claims for benefits under the Plan in a manner that is consistent with the standard of care in
Article 17 of this Agreement, Anthem will assume liability for payment of its legal fees and costs. However,
Anthem is not an insurer of benefits under the Plan nor does it underwrite the risk or otherwise assume any
risk for the payment of benefits under the Plan. Under all circumstances, Employer shall be liable to pay
Plan benefits awarded or paid by settlement, judgment, or otherwise.
Enterprise Administrative Services Agreement — October 2012 Master Template 15
City of Nashua 06/17/2013
