12.0 Provider Guidelines
12.1 PROVIDERnet Terms & Conditions
When Providers register for PROVIDERnet, they must accept and comply with the PROVIDERnet Terms & Conditions. Providers must accept the PROVIDERnet Terms & Conditions before creating their PROVIDERnet account. The PROVIDERnet Terms & Conditions must also be accepted each time a Claim is submitted through the PROVIDERnet website.
12.2 Payment of Claims
Policies provide coverage for an Eligible Expense. Pacific Blue Cross reimburses Claims up to the amount of the applicable Eligible Expense.
The Provider understands that a Policy may contain a Deductible, Co-payment, dollar limitations and maximums. Each Member is solely responsible to pay the Provider for any part of a Claim that is not an Eligible Expense.
12.3 Billing and Co-Payment
The Provider must submit a Claim for the actual cost of the Equipment or Services that is incurred by the Member. If a discount is given to the Member, the Provider must submit a Claim for the actual discounted cost that was incurred by the Member.
12.4 Insured and Non-Insured Charges
12.5 Claiming Deadline
Submit Claims as soon as possible at point of sale. In no event will payment be made on any Claim received later than two (2) months after the date Equipment or Services are provided to a Member.
12.6 Items not Picked Up
If a Member cancels a request for Equipment or is unable to pick up Equipment, the Provider may not submit a Claim for this Equipment.
12.7 Missed Appointments
12.8 Right to Recover Ineligible Expense
If Pacific Blue Cross determines that money paid to a Provider in connection with a Claim was to reimburse an Ineligible Expense, then the Provider will be required to pay the full amount of such Ineligible Expense to Pacific Blue Cross within thirty (30) days of receipt of a request from Pacific Blue Cross to pay the Ineligible Expense, or such other time agreed to in writing by Pacific Blue Cross.
12.9 Currency
Pacific Blue Cross pays each Eligible Expense in Canadian dollars.
12.10 Relatives
12.11 Termination and Suspension
In addition to any other rights to terminate or suspend access to PROVIDERnet set forth in the PROVIDERnet Terms & Conditions, Pacific Blue Cross reserves the right in its sole discretion and without notice to disable, suspend or terminate a PROVIDERnet account or access to PROVIDERnet, if Pacific Blue Cross reasonably believes: