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
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):
Notes:
You Pay
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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.
- Treatment of children up to age 22 with severe dental caries.
Notes:
- 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
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Benefit Description
Outpatient diagnostic testing performed and billed by a facility, such as:
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):
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