Emergency Services

Emergency Services

 

You do not need a referral from your health care provider or an approval from Blue Cross and Blue Shield before you obtain emergency medical care. As a member of this health plan, you will receive worldwide emergency coverage. These emergency medical services may include inpatient or outpatient services by health care providers who are qualified to furnish emergency medical care. This includes care that is needed to evaluate or stabilize your emergency medical condition. At the onset of an emergency medical condition that in your judgment requires emergency medical care, you should go to the nearest emergency room. If you need help, dial 911. Or, call your local emergency medical service system phone number. You will not be denied coverage for medical and transportation services that you incur as a result of your emergency medical condition. You usually need emergency medical services because of the sudden onset of a condition that manifests itself by symptoms of sufficient severity, including severe pain, which are severe enough that the lack of prompt medical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine to result in placing your life or health or the health of another (including an unborn child) in serious jeopardy or serious impairment of bodily functions or serious dysfunction of any bodily organ or part or, as determined by a provider with knowledge of your condition, to result in severe pain that cannot be managed without such care. Some examples of conditions that require emergency medical care are: suspected heart attacks; strokes; poisoning; loss of consciousness; convulsions; and suicide attempts.

Inpatient Emergency Admissions

Your condition may require that you be admitted into a hospital for inpatient emergency medical care. If this happens, you or the admitting facility (or someone on your behalf) must call Blue Cross and Blue Shield within 48 hours of your admission. (A health care facility that participates in your health care network should call Blue Cross and Blue Shield for you.) This call must include: your name; your ID number; the name of the health care facility; the date of admission; and the condition for which you are receiving treatment. This information is required so that Blue Cross and Blue Shield can evaluate and monitor the appropriateness of your inpatient health care services.

Outpatient Emergency Services

When you have an emergency medical condition, you should receive care at the nearest emergency room. If you receive emergency medical care at an emergency room of a hospital that does not participate in your health care network, your health plan will provide the same coverage that you would otherwise receive if you had gone to a hospital that does participate in your health care network.

When you are traveling outside of your service area, you may require emergency medical services or you may need urgent care. You usually need urgent care because an unforeseen illness or injury occurs and based on your location, you are not able to obtain treatment from your primary care provider or from a covered health care provider who participates in your health care network. Your health plan will cover urgent care when you are temporarily outside of your service area. If you are traveling outside of your service area and you need urgent care, you should go to the nearest appropriate health care facility. Then, after you receive that urgent care, you must call the Blue Cross and Blue Shield customer service office. You must make this call within 48 hours of receiving the urgent care. The Blue Cross and Blue Shield toll free phone number to call is shown on your ID card. You can call this number 24 hours a day, 7 days a week. (Your health plan will provide PCP/Plan Approved Benefits for one follow up visit outside of your service area if you need it. This one follow up visit does not need prior approval from Blue Cross and Blue Shield as long as you are still outside of your service area when you receive these services.)

Post-Stabilization Care

After your emergency medical condition has been evaluated and stabilized in the hospital emergency room, you may be ready to go home. Or, you may require further care. But, benefits will be provided only for the health care services and supplies that are covered by your health plan.

  • Admissions From the Emergency Room. Your condition may require that you be admitted directly from the emergency room into that hospital for inpatient emergency medical care. If this happens, you or the admitting facility (or someone on your behalf) must call Blue Cross and Blue Shield. (A health care facility that participates in your health care network should call Blue Cross and Blue Shield for you.) This call must be made within 48 hours of your admission. This call must include: your name; your ID number; the name of the health care facility; the date of admission; and the condition for which you are receiving treatment. This is required so that Blue Cross and Blue Shield can evaluate and monitor the appropriateness of your inpatient health care services.
  • Transfers to Other Inpatient Facilities. Your emergency room provider may recommend your transfer to another facility for inpatient care. If this happens, you or the admitting facility (or someone on your behalf) must call Blue Cross and Blue Shield. (A health care facility that participates in your health care network should call Blue Cross and Blue Shield for you.) This call must be made within 48 hours of your admission. This is required so that Blue Cross and Blue Shield can evaluate the appropriateness of the inpatient health care services.
  • Outpatient Follow Up Care. Your emergency room provider may recommend that you have outpatient follow up care. If this happens, the emergency room provider must call Blue Cross and Blue Shield to obtain an approval when the type of care that you need requires an approval from Blue Cross and Blue Shield. (See Part 4.) If you need to have more follow up care and an approval is required, you or your health care provider must obtain the approval from Blue Cross and Blue Shield.