2020 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(d). Emergency Services/Accidents
Page 84
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 should be aware that some Preferred (PPO) hospitals may have Non-preferred (non-PPO) professional providers on staff.
  • You must use Preferred providers in order to receive benefits, except in cases of medical emergency or accidental injury. Refer to the guidelines appearing below for additional information.
  • We provide benefits at Preferred benefit levels for emergency department services performed by both PPO and non-PPO providers when their services are related to an accidental injury or medical emergency. The Plan allowance for these services is determined by the contracting status of the provider. Note: For information regarding the Plan allowance, see Definitions on pages 135-136. If services are performed by non-PPO professional providers in a PPO facility, you will be responsible for your cost-share for those services, plus any difference between our allowance and the billed amount.
  • The calendar year deductible is $500 per person ($1,000 per Self Plus One or Self and Family enrollment).
What is an accidental injury?

An accidental injury is an injury caused by an external force or element such as a blow or fall and which requires immediate medical attention, including animal bites, and poisonings. (See Section 5(g) for dental care for accidental injury.)

What is a medical emergency?

A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are emergencies because they are potentially life threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability to breathe. There are many other acute conditions that we may determine are medical emergencies – what they all have in common is the need for quick action.

You are encouraged to seek care from Preferred providers in cases of accidental injury or medical emergency. However, if you need care immediately and cannot access a Preferred provider, we will provide benefits for the initial treatment provided in the emergency room of any hospital – even if the hospital is not a Preferred facility. We will also provide benefits if you are admitted directly to the hospital from the emergency room until your condition has been stabilized. In addition, we will provide benefits for emergency ambulance transportation provided by Preferred or Non-preferred ambulance providers if the transport is due to a medical emergency or accidental injury.

We provide emergency benefits when you have acute symptoms of sufficient severity – including severe pain – such that a prudent layperson, who possesses average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in serious jeopardy to the person’s health, or with respect to a pregnant member, the health of the member and the unborn child.