71 Participating Provider Status The Maximum Allowed Amount may vary depending upon whether the Provider is a Participating Provider or a Non-Participating Provider. A Participating Provider is a Provider who has signed a Participating agreement with the Plan. For Covered Services performed by a Participating Provider, the Maximum Allowed Amount for this Booklet is the rate the Provider has agreed with the Claims Administrator to accept as reimbursement for the Covered Services. Because Participating Providers have agreed to accept the Maximum Allowed Amount as payment in full for those Covered Services, they should not send you a bill or collect for amounts above the Maximum Allowed Amount. However, you may receive a bill or be asked to pay all or a portion of the Maximum Allowed Amount to the extent you have not met your Deductible or have a Copayment or Coinsurance. Please call Member Services for help in finding a Participating Provider or visit www.anthem.com. Providers who have not signed any contract with the Claims Administrator and are not in any of the Claims Administrator’s networks are Non-Participating Providers, subject to Blue Cross Blue Shield Association rules governing claims filed by certain ancillary providers. For Covered Services you receive from an Non-Participating Provider, the Maximum Allowed Amount for this Plan will be one of the following as determined by us: 1. An amount based on the non-Participating Provider fee schedule/rate, which the Plan has established in its discretion, and which the Plan reserves the right to modify from time to time, after considering one or more of the following: reimbursement amounts accepted by like/similar providers contracted with the Claims Administrator, reimbursement amounts paid by the Centers for Medicare and Medicaid Services for the same services or supplies, and other industry cost, reimbursement and utilization data; or 2. An amount based on reimbursement or cost information from the Centers for Medicare and Medicaid Services (“CMS”). When basing the Maximum Allowed amount upon the level or method of reimbursement used by CMS, the Claims Administrator will update such information, which is unadjusted for geographic locality, no less than annually; or 3. An amount based on information provided by a third party vendor, which may reflect one or more of the following factors: (1) the complexity or severity of treatment; (2) level of skill and experience required for the treatment; or (3) comparable Providers’ fees and costs to deliver care, or 4. An amount negotiated by the Claims Administrator or a third party vendor, which has been agreed to by the Provider. This may include rates for services coordinated through case management, or 5. An amount based on or derived from the total charges billed by the Non-Participating Provider. Providers who are not contracted for this product, but are contracted for other products with the Claims Administrator are also considered Non-Participating. For this Plan, the Maximum Allowed Amount for services from these Providers will be one of the five methods shown above unless the contract between the Claims Administrator and that Provider specifies a different amount. For Covered Services rendered outside the Claims Administrator’s Service Area by Non-Participating Providers, claims may be priced using the local Blue Cross Blue Shield plan’s Non-Participating provider fee schedule / rate or the pricing arrangements required by applicable state or federal law. In certain situations, the Maximum Allowed Amount for out of area claims may be based on billed charges, the pricing the Plan would use if the healthcare services had been obtained within the Claims Administrator’s Service Area, or a special negotiated price.