2020 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
 
Important things you should keep in mind about these benefits:
 
  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
     
  • Be sure to read Section 4, Your Costs for Covered Services, for valuable information about how cost-sharing works. Also, read Section 9 for information about how we pay if you have other coverage, or if you are age 65 or over.
     
  • YOU MUST GET PRECERTIFICATION FOR HOSPITAL STAYS; FAILURE TO DO SO WILL RESULT IN A $500 PENALTY. Please refer to the precertification information listed in Section 3 to be sure which services require precertification.
     
  • YOU MUST GET PRECERTIFICATION FOR RESIDENTIAL TREATMENT CENTER STAYS. Please refer to the precertification information listed in Section 3.
     
  • Note: Observation services are billed as outpatient facility care. Benefits for observation services are provided at the outpatient facility benefit levels described on page 77. See page 134-135 for more information about these types of services.
     
  • YOU MUST GET PRIOR APPROVAL for services such as the following: surgery for morbid obesity; surgical correction of congenital anomalies; and oral maxillofacial surgeries/surgery on the jaw, cheeks, lips, tongue, roof and floor of the mouth, and related procedures.
     
  • YOU MUST GET PRIOR APPROVAL for gender reassignment surgery. See page 20 for prior approval and page 60 for the surgical benefit.
     
  • When PRIOR APPROVAL IS REQUIRED for a surgical procedure and the surgery is performed on an inpatient basis, YOU MUST ALSO GET PRECERTIFICATION for the inpatient admission.
     
  • You should be aware that some Preferred (PPO) inpatient facilities may have Non-preferred (Non-PPO) professional providers on staff.
     
  • You must use Preferred providers in order to receive benefits. See page 18 for the exceptions to this requirement.
     
    • You are responsible for the applicable cost-sharing amounts for care performed and billed by Preferred professional providers in the outpatient department of a Preferred hospital.
       
  • We base payment on whether a facility or a healthcare professional bills for the services or supplies. You will find that some benefits are listed in more than one Section of the brochure. This is because how they are paid depends on what type of provider or facility bills for the service.
     
  • The services listed in this Section are for the charges billed by the facility (i.e., hospital or surgical center) or ambulance service, for your inpatient or outpatient surgery or care. Any costs associated with the professional charge (i.e., physicians, etc.) are listed in Sections 5(a) or 5(b).
     
  • The calendar year deductible is $500 per person ($1,000 per Self Plus One or Self and Family enrollment).
     
  • Benefits for certain self-injectable drugs are limited to once per lifetime per therapeutic category of drugs when obtained from a covered provider other than a pharmacy under the pharmacy benefit. You must use a Preferred pharmacy, thereafter. This benefit limitation does not apply if you have primary Medicare Part B coverage. See page 95 for information about specialty drug fills from a Preferred pharmacy. Medications restricted under this benefit are available on our FEP Blue Focus Specialty Drug List. Visit www.fepblue.org/specialtypharmacy or call us at 888-346-3731.
 

List Item:

important
definitions
limitations
exclusions
overview
precertification
hospital
failure
penalty
fail
observations
surgery
prior
approval
morbid
obesity
bariatric
surgical
congenital
anomalies
maxillofacial
surgeries
jaw
cheeks
lips
tongue
roof
floor
mouth
reassigment
gender
preferred
PPO
non-preferred
Non-ppo
self-injectable
therapeutic
drugs
pharmacy
medicare
medications