2020 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(d). Emergency Services/Accidents
Page 85


Note: The calendar year deductible applies to almost all benefits in this Section. We say “(No deductible)” when it does not apply.
 
Benefit Description

Accidental Injury

When you receive care for your accidental injury within 72 hours of the injury, we cover:

 
  • Professional provider services in the emergency room, hospital outpatient department, or provider’s office, including professional care, diagnostic studies, radiology services, laboratory tests, and pathology services, when billed by a professional provider
     
  • Outpatient hospital services and supplies, including professional provider services, diagnostic studies, radiology services, laboratory tests, and pathology services, when billed by the hospital
     
  • Urgent care center services and supplies, including professional providers’ services, diagnostic studies, radiology services, laboratory tests and pathology services, when billed by the urgent care center provider
     
Notes:
 
  • All follow-up care must be performed and billed for by Preferred providers to be eligible for benefits.
     
  • If you are treated by a non-PPO professional provider in a PPO facility, you will be responsible for any difference between our allowance and the billed amount.
     
  • See Section 5(g) for dental benefits for accidental injury.

You Pay
Preferred: Nothing (no deductible)

Non-preferred professional providers (Participating and Non-participating):

 
  • Participating: Nothing (no deductible)
     
  • Non-participating: Any difference between our allowance and the billed amount (no deductible)

Non-preferred facilities (Member/Non-member):
 
  • Member: Nothing (no deductible)
     
  • Non-member: Nothing (no deductible)

Note: The benefits described above apply only if you receive care in connection with, and within 72 hours after, an accidental injury. For services received after 72 hours, regular benefits apply. See Sections 5(a), 5(b), and 5(c) for the benefits we provide.
 
Benefit Description

When you are admitted to the hospital within 72 hours of an accidental injury, your inpatient admission is covered regardless of the hospital’s network status.

Notes:

 
  • See Section 5(c) for services associated with an inpatient admission.
     
  • All follow-up care must be performed and billed for by Preferred providers to be eligible for benefits.

You Pay
30% of the Plan allowance
 
Benefit Description

When you are admitted to the hospital within 72 hours of an accidental injury, the inpatient professional care you receive is covered regardless of the provider’s network status.

Notes:

 
  • See Section 5(a) for inpatient professional services.
     
  • All follow-up care must be performed and billed for by Preferred providers to be eligible for benefits.
     
  • For additional information, see Section 5(a), page 38.
     
  • For more information regarding non-provider exceptions, see page 18.

You Pay
Preferred facilities: 30% of the Plan allowance

Non-preferred facilities (Member and Non-member):
  • Member: 30% of the Plan allowance
     
  • Non-member: 30% of the Plan allowance, plus any difference between our allowance and the billed amount
 
Benefit Description
Not covered:

 
  • Oral surgery except as shown in Section 5(b)
     
  • Injury to the teeth while eating
     
  • Emergency room professional charges for shift differentials

You Pay
All charges