Health Plan Partners with Green Light Cost Management to Obtain Lower Payments for Non-Network Claims for You and the Health Plan

The New Payment/Reimbursement Process for Non-Network Claims

The DGA–Producer Health Plan has partnered with Green Light Cost Management to help negotiate lower rates for non-network claims and eliminate balance billing whenever possible. With Green Light, the Health Plan will be better able to reduce out-of-pocket costs when you use non-network providers, as well as reduce overall costs to the Health Plan.

In order to provide Green Light with the opportunity to try to negotiate better pricing for you, it is important that you do not pay the non-network provider up front. (See Tips to Avoid Paying the Entirety of Your Non-Network Medical Bill Up Front.) Instead, ask your provider to submit your claim electronically through the Health Plan’s normal claims filing process. If you pay up front, you may lose out on potential savings that could have been achieved through the negotiation process with Green Light and be subject to a lower reimbursement amount from the Health Plan for your claim. If you disagree with the reimbursement amount, you may file an appeal with the Health Plan to have the reimbursement amount reviewed.

“Reasonable and Customary” Re-Defined

The definition of “Reasonable and Customary” under the Health Plan, which is used to determine the standard payment amounts for non-network claims, is changing effective January 16, 2024 to 150% of the Medicare reimbursement rate. Prior to this change, “Reasonable and Customary” was defined by the Health Plan as the charge or fee level that is equal to or less than the charge that 80% of the physicians of a similar specialization in a given geographic area would charge for a specified procedure.

Beginning with claims received by the Health Plan on or after January 16, 2024, the “Reasonable and Customary” pricing standard the Health Plan uses to pay non-network claims will be defined as the charge or fee that is the lesser of: (1) actual billed charges; (2) 150% of the applicable Medicare reimbursement rate for a specified procedure; or (3) in the event there is no Medicare reimbursement rate for a specified procedure or it cannot be determined based on the information submitted, the amount that would be paid to a similar provider for the same or similar service or item in the same geographic location or locality. The schedules of the maximum reasonable and customary rates are adjusted periodically.

The Health Plan’s maximum allowable charge for any medical procedure or service from a non-network provider will not exceed the applicable Reasonable and Customary amount noted above. You are responsible for any charges from non-network providers in excess of the maximum allowable charge and all non-covered expenses, except with respect to emergency services, non-emergency services received from a non-network provider at certain network facilities, and air ambulance services furnished by non-network providers.

Here’s How It Works:

For U.S. claims:

Submit your non-network claim to Blue Cross via your online Anthem account, fax or mail. DO NOT submit claims to the Health Plan office.
Your non-network claim is then received by the Health Plan.
The Health Plan, in partnership with Green Light, will determine the portion of the claim’s billed amount the Health Plan will pay under its terms.

If the claim is less than $500, the Health Plan will pay the Reasonable and Customary amount for any covered expenses, as defined above (usually 150% of Medicare’s reimbursement rate). You will be responsible for any amounts in excess of the Reasonable and Customary amount, plus any expenses not covered under Health Plan rules.
NOTE: When possible, similar or related claims will be bundled to meet the $500 threshold.
If the claim is more than $500 and you have not yet paid the provider:
1. Green Light will attempt to negotiate with the provider on your behalf to determine a mutually agreeable allowance.
2. If Green Light is able to negotiate a more favorable rate with your non-network provider, you will be responsible for any applicable deductible and co-insurance based upon the negotiated rate on covered expenses. As part of the pricing arrangement with Green Light, the non-network provider will agree not to balance bill you for any remaining charges.
If Green Light and your provider are unable to reach a negotiated rate agreement, the Health Plan will pay the standard Reasonable and Customary rate, as defined above (usually 150% of Medicare’s reimbursement rate) on any covered expenses. You may be balance billed by the non-network provider for any amounts in excess of the Reasonable and Customary rate, plus any expenses not covered under Health Plan rules.
If the claim is more than $500 and you have already paid the provider, the Health Plan will reimburse you at the Reasonable and Customary amount, as defined above (usually 150% of Medicare’s reimbursement rate) for any covered expenses. If you disagree with the reimbursement amount, you may file an appeal with the Health Plan to have the reimbursement amount reviewed.

For international claims:

Submit an International Claim Form along with your itemized bill to BlueCross BlueShield Global Core.
You will be reimbursed the Reasonable and Customary rate of 150% of the Medicare rate according to the New York City metropolitan area. If you disagree with the reimbursement amount, you may file an appeal with the Health Plan to have the reimbursement amount reviewed.

Tips to Avoid Paying the Entirety of Your Non-Network Medical Bill Up Front

Waiting to pay until after your claim has been submitted could save you money.

Ask your provider to submit your claim electronically through the normal claims filing process. This will allow Green Light the opportunity to negotiate better pricing for you. If you pay up front, you may lose potential savings that could have been achieved through the negotiation process from Green Light.
Ask your provider for the least amount you can pay at your appointment. If you must pay in person, pay as little as possible to increase your chances of full reimbursement after the claim is submitted.
Negotiate a lower price for the services with your provider. If you must pay your entire bill to receive services, negotiate the price using Medicare’s rate as a standard. Providers may be willing to discount the initial quoted price for patients who pay up front. To find Medicare rates, go to www.medicare.gov/procedure-price-lookup/.