As of May 1, 2021 the Fountain Life has a custom partially self-funded health plan. While Fountain Life is the ultimate payer, the Plan is facilitated by the Third Party Administrator, American Plan Administrators (APA). This is an open-access plan type, similar to an indemnity plan, giving the members the freedom to visit any facility they choose without reduced benefits for out-of-network providers.
The process is actually very simple. As a provider, you treat the patient and collect any applicable co-pay at the time of service. Medical claims are then submitted to Cambridge and then repriced and submitted to APA for payment.
Claims may be submitted to:
Cambridge under the Payer ID: 95606
Claims unable to be submitted electronically can be mailed to:
American Plan Administrators
PO Box 477
Arnold, MD 21012
Facility providers will be reimbursed at the Allowable Charge, as described below.
“Allowable Charge” for a treatment, supply, or other services rendered is determined by the Plan, at the Plan’s discretion, by determining the amount established by a negotiated arrangement if one exists, or the lesser of:
For Covered Charges rendered by a physician or other professional provider in a geographic area where applicable law dictates the maximum amount that can be billed by the rendering provider, the Allowable Charge shall mean the amount established by applicable law for that Covered Charge.
The Allowable Charges shall not include:
Nothing in this section shall be construed to limit the Plan’s discretion to deem a greater amount payable than the lesser of any of the above-referenced amounts. Furthermore, the Plan is not obligated to consider all factors. In the event that the Plan determines that insufficient information is available to identify the Allowable Charge for a specific service or supply using the listed guidelines above, the Plan reserves the right, in its sole discretion, to determine any Allowable Charge amount for certain conditions, services and supplies using accepted industry-standard documentation, applied without discrimination to any Covered Person.
Specified Benefit Amount
“Specified Benefit Amount” means the charges for services and supplies, listed and included as Covered Charges under the Plan, which are Medically Necessary for the care and treatment of Illness or Injury, but only to the extent that such fees do not exceed the Specified Benefit Amount. The
determination that a charge does not exceed the Specified Benefit Amount include, but are not limited to, the following guidelines:
•1.40 times the Medicare allowed amount for a Hospital facility, facility which isowned and operated by a Hospital, or an Ambulatory Surgery Centers;
Usual, Customary and Reasonable
“Usual, Customary and Reasonable” means the common paid amount for the same or comparable service in the geographic area in which the service or supply is furnished. Usual, Customary and Reasonable payment is based upon:
Nothing in this section shall be construed to limit the discretion of thePlan. The Plan is not obligated to consider all factors listed above.
If you have questions regarding the plan benefit, or want an estimate of theexpected reimbursement, you can call:
American Plan Administrators (718) 625-6300 x315