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Provider Choices:
Your choice of health care provider can make a
difference in the amount you pay for covered
services and the benefits you receive.
You have a choice between selecting a
Participating Provider (one that contracts
with BCBSNM to provide services at a potentially
reduced rates) or a Nonparticipating Provider
(one that does not contract with BCBSNM).
The amount the Pool pays for a covered service
is always based on the “covered charge” for that
service. The covered charge is always less than
or equal to the provider’s billed amount. You
may have to pay the difference between the
billed amount and the covered charge.
The advantages of choosing a Participating
Provider is that:
- the provider will file your claim for
you, and
- you will not have to pay the difference
between the amount billed by the provider
and the covered charge for that service.
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Example 1.
Participating Provider Claim Payment
(80% Plan; Deductible is met): |
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| Provider's billed charge |
$2000.00 |
| Covered charge (maximum
amount that can be considered for
benefit payment) |
$1800.00 |
| The Pool's payment to provider
(80% of $1800) |
$1440.00 |
| Member coinsurance (20% of
$1800) applied to out-of-pocket limit |
-$360.00 |
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Amount in excess of covered charge
($2000 - $1800) NOT applied to
out-of-pocket limit; but participating
provider will not bill member for this
amount. |
-$0.00 |
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Total amount due from policyholder:
Member coinsurance ($360) |
$360 |
When you choose a Nonparticipating
Provider, the provider:
- does not have to file your claim for
you, and
- you may have to pay the difference
between the amount billed by the provider
and the covered charge for that services (it
is up to the provider).
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Example 2.
Nonparticipating Provider Claim Payment
(80% Plan; Deductible is met): |
|
| Provider's billed charge |
$2000.00 |
| Covered charge (maximum
amount that can be considered for
benefit payment) |
$1800.00 |
| The Pool's payment to provider
(80% of $1800) |
$1440.00 |
| Member coinsurance (20% of
$1800) applied to out-of-pocket limit |
-$360.00 |
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Amount in excess of covered charge
($2000 - $1800) NOT applied to
out-of-pocket limit; but participating
provider will not bill member for this
amount. |
-$200.00 |
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Total amount due from policyholder:
Member coinsurance ($360) |
$560 |
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