“the reasonable and customary amount,” “the usual, customary and reasonable amount,” “the prevailing rate' or other similar terms that base payment on what other health care providers in a geographic area charge for their services (the U&C Rate).a published fee schedule, which may be the rates used by Medicare or a percentile of the FAIR Health fee schedule, referred to in the member’s Summary of Benefits or the attachment to the member’s Certificate of Coverage.the standard reimbursement rate in the member’s contract (This rate is established by the employer or health plan sponsor for out-of-network reimbursement and defined in the member’s Summary of Benefits or the attachment to the member’s Certificate of Coverage).the discounted charges if the out-of-network provider is in another network that has an arrangement with the EmblemHealth companies (wrap network) to give a discount off charges.the out-of-network provider’s actual charge billed to the member.In most cases, the EmblemHealth companies will pay for the amount that is the lower of: This fee schedule is also used when a benefit plan refers to a usual or customary rate or other similar description. In some cases, the applicable fee schedule is one published by FAIR Health, Inc., an independent nonprofit organization selected by the Attorney General of the State of New York. When our plan members with out-of-network benefits receive covered services from out-of-network providers, the EmblemHealth companies calculate the allowed amount for that service and pay based on the applicable fee schedule as stated in the member’s benefit plan. These providers are called out-of-network for elective services. Members with out-of-network benefits may use doctors and other health care providers who are not in the EmblemHealth network of participating providers. Some of the health plans administered or insured by the EmblemHealth companies provide out-of-network health care coverage some of our plans cover only out-of-network services for treatment of an emergency condition. These providers are called in-network and agree to accept our contracted rates. The EmblemHealth companies - Emblem Health Incorporated, EmblemHealth HMO Select, Inc., EmblemHealth Health Plan of New York and EmblemHealth Insurance Company of New York- negotiate rates with doctors, dentists and other health care providers.

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