70 Claims Payment This section describes how the Claims Administrator reimburses claims and what information is needed when you submit a claim. A claim must be filed for you to get benefits. Many Hospitals, Doctors and Other Providers will submit a claim for you. If you file the claim, use a claim form as described later in this section. Maximum Allowed Amount General This section describes how the Claims Administrator determines the amount of reimbursement for Covered Services. Reimbursement for services rendered by Participating and Non-Participating Providers is based on this Booklet’s Maximum Allowed Amount for the Covered Service that you receive. Please see “Inter-Plan Arrangements” later in this section for additional information. The Maximum Allowed Amount for this Plan is the maximum amount of reimbursement allowed for services and supplies: • That meet the definition of Covered Services, to the extent such services and supplies are covered under your Plan and are not excluded; • That are Medically Necessary; and • That are provided in accordance with all applicable preauthorization, utilization management or other requirements set forth in your Booklet. You will be required to pay a portion of the Maximum Allowed Amount to the extent you have not met your Deductible or have a Copayment or Coinsurance. Except for Surprise Billing Claims, when you receive Covered Services from a Non-Participating Provider, you may be responsible for paying any difference between the Maximum Allowed Amount and the Provider’s actual charges. This amount can be significant. *Surprise Billing Claims are described in the “Consolidated Appropriations Act of 2021 Notice” at the front of this Booklet. Please refer to that section for further details. When you receive Covered Services from Provider, the Claims Administrator will, to the extent applicable, apply claim processing rules to the claim submitted for those Covered Services. These rules evaluate the claim information and, among other things, determine the accuracy and appropriateness of the procedure and diagnosis codes included in the claim. Applying these rules may affect the Claims Administrator’s determination of the Maximum Allowed Amount. The Claims Administrator’s application of these rules does not mean that the Covered Services you received were not Medically Necessary. It means the Claims Administrator had determined that the claim was submitted inconsistent with procedure coding rules and/or reimbursement policies. For example, your Provider may have submitted the claim using several procedure codes when there is a single procedure code that includes all of the procedures that were performed. When this occurs, the Maximum Allowed Amount will be based on the single procedure code rather than a separate Maximum Allowed Amount for each billed code. Likewise, when multiple procedures are performed on the same day by the same Doctor or other healthcare professional, the Plan may reduce the Maximum Allowed Amounts for those secondary and subsequent procedures because reimbursement at 100% of the Maximum Allowed Amount for those procedures would represent duplicative payment for components of the primary procedure that may be considered incidental or inclusive.