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
Page 77
Benefit Description

Outpatient Hospital or Ambulatory Surgical Center (cont.)

Outpatient surgical and treatment services performed and billed by a facility, such as (continued):

  • Cardiac rehabilitation
  • Observation services

    Note: All outpatient services billed by the facility during the time you are receiving observation services are included in the cost-share amounts shown here. Please refer to Section 5(a) for services billed by professional providers during an observation stay and page 73 for information about benefits for inpatient admissions.

  • Pulmonary rehabilitation
  • Hospital-based clinic visits
  • Outpatient hospital services and supplies related to:
    • Treatment of children up to age 22 with severe dental caries.
    • Dental procedures only when a non-dental physical impairment exists that makes the hospital setting necessary to safeguard the health of the patient. See Section 5(g), Dental Benefits, page 104.

  • See pages 84-86 for our payment levels for care related to a medical emergency or accidental injury.
  • See pages 49-50 for our coverage of family planning services.
  • See page 79 for outpatient drugs, medical devices, and durable medical equipment billed for by a facility.
  • See page 74 for maternity care provided in an outpatient facility.

You Pay
See previous page
Benefit Description

Outpatient diagnostic testing performed and billed by a facility, such as:

  • Angiographies
  • Bone density tests
  • CT scans*/MRIs*/PET scans*
  • Genetic testing*

    Note: We cover specialized diagnostic genetic testing billed for by a facility, such as the outpatient department of a hospital, as shown here. See pages 43-44 for coverage criteria and limitations.

  • Nuclear medicine
  • Sleep studies
  • Cardiovascular monitoring
  • EEGs
  • Ultrasounds
  • Neurological testing
  • X-rays (including set-up of portable X-ray equipment)
  • EKGs
  • Laboratory tests and pathology services

Note: For outpatient facility care related to maternity, including outpatient care at birthing facilities, see Maternity – Facility, page 74 in this Section.

*Prior approval is required.

You Pay
Preferred facilities: 30% of the Plan allowance

Non-preferred facilities (Member/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
Outpatient Hospital or Ambulatory Surgical Center - continued on next page