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Direction of Pay All benefits payable by the Plan are assignable only to participating providers. The Plan has the right to make payment to covered providers for covered services that they provide while there is in effect an agreement between the Plan’s network and the provider allowing for direct payment. In the absence of such an agreement the Plan may pay to the enrollee and only the enrollee any benefits allowed herein. In addition, the Plan reserves the right not to recognize an enrollee’s attempted assignment to, or direction to pay, another. If a covered provider has not been offered an agreement to participate in the Plan’s network, the Plan will recognize an enrollee’s direction to pay the provider. To the extent permitted by law, neither the benefits or payments under the Plan will be subject to the claim of creditors or any legal process.

Patient Audit Program Participants are encouraged to be a patient-auditor. Participants should check medical bills to be sure they are correct. The Patient Audit Program provides a financial incentive for participants to help lower the Plan’s cost as well as their own coinsurance costs for health care. This financial incentive is 50% of the amount recovered by the Plan due to a billing error, up to a maximum of $1,000 per calendar year per participant.

A patient audit incentive payment will be issued when all of the following occur:

  • 1.

    Incorrect claim for covered medical expense is filed and benefits are paid,

  • 2.

    The participant verifies with the provider that there is an error in the bill,

  • 3.

    A corrected claim is filed, benefits are adjusted, and the overpayment is recovered by the Plan, and

  • 4.

    Written request for a patient audit incentive payment is sent to the Department of Finance and Administration, Office of Insurance.

Information required when requesting a patient audit incentive payment includes copies of the original and revised billings from the provider, both the incorrect and adjusted explanation of benefits from Blue Cross & Blue Shield, and copies of any other available documentation relative to the overpayment and/or adjustment of the claim. Failure to provide the required documentation and related information will result in the request to receive an incentive payment from the Patient Audit Program being denied.

If the Department of Finance and Administration, Office of Insurance determines that an overcharge was made, 50% of the amount refunded to the Plan, up to a maximum of $1,000 per calendar year, will be paid to the enrollee. If it is determined that no error was made or that the request does not qualify under the Patient Audit Program, an explanation will be sent. Payment errors made as a result of Blue Cross & Blue Shield’s actions are not eligible for patient audit incentive payments.

In the event a patient audit incentive payment request is made on behalf of a deceased Plan participant, legal proof of the identity and address of the administrator of the Plan participant’s estate and information as to the status of the estate will be required.

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