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Allowed amount, medical services
Allowed amount is the most the plan pays for a specific covered service or supply. The allowed amount is determined as follows:
- For preferred (network for UMP Plus) providers that are within the Regence service area, the preferred provider organization contract with Regence BlueShield is the relevant contract that determines the allowed amount. For preferred (network for UMP Plus) providers that are outside the Regence service area, the contract with another Blue Cross or Blue Shield organization in the BlueCard® program for its “Preferred Provider Organization (‘PPO’) network” is the relevant contract that determines the allowed amount.
- For participating providers that are within the Regence service area, the participating provider contract with Regence BlueShield is the relevant contract that determines the allowed amount. For participating providers that are outside the Regence service area, the contract with another Blue Cross or Blue Shield organization in the BlueCard® program is the relevant contract that determines the allowed amount. Note: This only applies to UMP Classic and UMP CDHP.
- For out-of-network providers (providers not contracted with Regence BlueShield) within the Regence service area, the amount Regence has determined to be reasonable charges for covered services and supplies.
The allowed amount may be based upon the billed charges for some services, as determined by Regence or as otherwise required by law. Where, although it does not qualify as a preferred (network for UMP Plus) provider hereunder, one of these providers has a contract with Regence, the provider will accept the allowed amount as payment in full.
- For out-of-network providers accessed through the BlueCard Program, the allowed amount is the lower of the provider’s billed charges and the amount that the other Blue plan identifies as the amount on which it would base a payment to that provider.
Under the BlueCard Program, when you access covered services within the geographic area served by a Host Blue, Regence will remain responsible for fulfilling contractual obligations. However, the Host Blue is responsible for contracting with and generally handling all interactions with its network providers. Whenever you access covered services outside Regence’s service area and the claim is processed through the BlueCard Program, the amount you pay for covered services is calculated based on the lower of:
- The billed covered charges for your covered services; or
- The negotiated price that the Host Blue makes available to Regence.
Often, this “negotiated price” will be a simple discount that reflects an actual price that the Host Blue pays to your health care provider. Sometimes, it is an estimated price that takes into account special arrangements with your health care provider or provider group that may include types of settlements, incentive payments, and/or other credits or charges. Occasionally, it may be an average price, based on a discount that results in expected average savings for similar types of health care providers after taking into account the same types of transactions as with an estimated price.
Estimated pricing and average pricing, going forward, also take into account adjustments to correct for over- or underestimation of modifications of past pricing for the types of transaction modifications noted above. However, such adjustments will not affect the price Regence uses for your claim because they will not be applied retroactively to claims already paid.
Laws in a small number of states may require the Host Blue to add a surcharge to your calculation. If any state laws mandate other liability calculation methods, including a surcharge, Regence would then calculate your liability for any covered services according to applicable law.
Charges in excess of the allowed amount are not reimbursable. For questions regarding the basis for determination of the allowed amount, please call UMP Customer Service at 1-888-849-3681 (TRS: 711).