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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. Green Light will attempt 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 if possible. (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. 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

When determining the Reasonable and Customary Charge—which is the amount the Health Plan will reimburse you for a covered medical service rendered by a non-network provider—the Health Plan generally uses two pricing standards: (1) 80% of the FAIR Health* rate, or (2) 150% of the Medicare reimbursement rate for that service, though there are exceptions. Beginning January 16, 2024, the Reasonable and Customary Charge will be determined as follows:

  • The Health Plan will reimburse non-network claims at 80% of the FAIR Health standard under the circumstances below:
    1. When you pay upfront and FAIR Health pricing exists; or
    2. When Green Light negotiations with the provider are unsuccessful.
  • The Health Plan will use the 150% of Medicare reimbursement rate when a FAIR Health rate does not exist for the service provided.
  • When you have not paid your non-network provider upfront, Green Light will attempt to negotiate with your provider regarding your billed charges. If Green Light is successful in negotiating a better rate, you will be protected from balance billing, and you and the Health Plan will benefit from lower pricing.

    Non-network providers will be prevented from balance billing you only when the claim has been successfully negotiated by Green Light. In all other cases, you may be subject to balance billing by the non-network provider. Whenever possible, you should negotiate pricing before making an upfront payment.

  • When the Health Plan is not your primary plan, the Health Plan will begin by determining how much it would have paid had there been no other group coverage. Next it will find out what the primary plan paid. Then it will make a payment for the difference, if any, between the greater of the allowable amount and the amount paid by the primary plan, but not to exceed the amount the Health Plan would have paid if it was primary.
  • When there are Plan limits for a covered service (e.g., chiropractic and ambulatory services), the Health Plan will reimburse up to the plan limit amount. See Article 1, Section 1 Visit and Benefit Amount Limitations of the Health Plan’s March 2020 Summary Plan Description for more information.

The Health Plan’s allowable charge for any medical procedure or service from a non-network provider is based on the applicable Reasonable and Customary amount. You are responsible for any charges from non-network providers in excess of the maximum allowable charge, unless otherwise negotiated by Green Light, 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:

  1. 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.
  2. Your non-network claim is then received by the Health Plan.
  3. 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. 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.
    3. 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 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, 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:

  1. Submit an International Claim Form along with your itemized bill to BlueCross BlueShield Global Core.
  2. You will be reimbursed the Reasonable and Customary 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.

  1. 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.
  2. 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.
  3. 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/.

*FAIR Health is an independent organization that compiles healthcare claims records from around the U.S. to provide cost estimates (based on geography) for most medical services.