Accidental Injury

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

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

List Item:
emergency
accidents
accidental
injury
professional
inpatient
outpatient
diagnostic
radiology
laboratory
pathology
urgent
care
center
non-ppo
ppo
preferred
non-preferred
follow-up
non-provider
oral
teeth