Part 2 Definitions The following are shown in italics in this Benefit Description and in any that apply to riders your benefits under this Medex plan. These terms will give you a better understanding of your benefits. Accident Any bodily injury that you sustain as the direct result of an This does not include any accident. injury that is the result of a disease, bodily infirmity or any other cause. Medex provides benefits as described in this Benefit Description for treatment of accidents. Allowed Charge The charge that is used to calculate payment of the Medex benefits described in this Benefit Description. The depends on whether a service is: eligible for benefits under allowed charge or eligible for benefits under Medex only. Medicare; For a service eligible for benefits under the term has the same Medicare, allowed charge meaning as fee schedule amount, payment rate or reasonable charge does under Medicare. sets the for a service according to a special formula. (See your Medicare allowed charge handbook for details.) You may have to pay the amount of the actual charge that is Medicare more than the (See Part 9.) allowed charge. For a service eligible for benefits Medex only, for that have a covered providers payment agreement with the is based on the Blue Cross and Blue Shield, allowed charge provisions of that provider's payment agreement. In most cases, you do not have to pay the amount of the actual charge that is more than the But, you must pay this allowed charge. excess amount when are furnished by professional providers and you could covered services have received benefits or services from someone else without charge or you have received or will receive payment from another person or insurance company. Once these payments from the other person or insurance company have been applied to your provider balances and used up, you do not have to pay the excess charge. For that do not have a payment agreement with covered providers Blue Cross and Blue the is set by It is the amount that Shield, allowed charge Blue Cross and Blue Shield. Blue determines to be in the range of fees most often made by similar Cross and Blue Shield providers for the same service or supply. This amount is usually less than the provider’s actual charge. In this case, you must pay the amount that is more than the allowed charge.
Part 2 Definitions The following are shown in italics in this Benefit Description and in any riders that apply to your benefits under this Medex plan. These terms will give you a better understanding of your benefits. Accident Any bodily injury that you sustain as the direct result of an accident. This does not include any injury that is the result of a disease, bodily infirmity or any other cause. Medex provides benefits as described in this Benefit Description for treatment of accidents. Allowed Charge The charge that is used to calculate payment of the Medex benefits described in this Benefit Description. The allowed charge depends on whether a service is: eligible for benefits under Medicare; or eligible for benefits under Medex only. For a service eligible for benefits under Medicare, the term allowed charge has the same meaning as fee schedule amount, payment rate or reasonable charge does under Medicare. Medicare sets the allowed charge for a service according to a special formula. (See your Medicare handbook for details.) You may have to pay the amount of the actual charge that is more than the allowed charge. (See Part 9.) For a service eligible for benefits Medex only, for covered providers that have a payment agreement with Blue Cross and Blue Shield, the allowed charge is based on the provisions of that provider's payment agreement. In most cases, you do not have to pay the amount of the actual charge that is more than the allowed charge. But, you must pay this excess amount when covered services are furnished by professional providers and you could have received benefits or services from someone else without charge or you have received or will receive payment from another person or insurance company. Once these payments from the other person or insurance company have been applied to your provider balances and used up, you do not have to pay the excess charge. For covered providers that do not have a payment agreement with Blue Cross and Blue Shield, the allowed charge is set by Blue Cross and Blue Shield. It is the amount that Blue Cross and Blue Shield determines to be in the range of fees most often made by similar providers for the same service or supply. This amount is usually less than the provider’s actual charge. In this case, you must pay the amount that is more than the allowed charge.