Common use of Claims for Emergency or Urgent Services Clause in Contracts

Claims for Emergency or Urgent Services. If you receive Emergency or Urgent Services from a Non-Participating Provider, you may be required to pay the charges in full and submit a claim to Blue Shield to request reimbursement. Blue Shield may send the payment to the Subscriber or directly to the Non-Participating Provider. Claim forms are available at xxxxxxxxxxxx.xxx. Please submit your claim form and medical records within one year of the service date. See the Out-of-area services section in the Other important information about your plan section for more information on claims for Emergency or Urgent Services outside of California. Your coverage This section explains eligibility and enrollment for this plan. It also describes the terms of your coverage, including information about effective dates and the different ways your coverage can end. Eligibility for this plan To be eligible for coverage as a Subscriber, you must meet all of your Employer’s eligibility requirements and complete any waiting period established by your Employer. Dependent eligibility To be eligible for coverage as a Dependent, you must: • Be listed on the enrollment form completed by the Subscriber; and • Be the Subscriber’s spouse, Domestic Partner, or be under age 26 and the child of the Subscriber, spouse, or Domestic Partner. o For the Subscriber’s spouse to be eligible for this plan, the Subscriber and spouse must not be legally separated. o For the Subscriber’s Domestic Partner to be eligible for this plan, the Subscriber and Domestic Partner must have a registered domestic partnership (except as otherwise permitted by your Employer). o “Child” includes a stepchild, newborn, child placed for adoption, child placed in xxxxxx care, and child for whom the Subscriber, spouse, or Domestic Partner is the legal guardian. It does not include a grandchild unless the Subscriber, spouse, or Domestic Partner has adopted or is the legal guardian of the grandchild.

Claims for Emergency or Urgent Services. If you receive Emergency or Urgent Services from a Non-Participating Provider, you may be required to pay the charges in full and submit a claim to Blue Shield to request reimbursement. Blue Shield may send the payment to the Subscriber or directly to the Non-Participating Provider. Claim forms are available at xxxxxxxxxxxx.xxx. Please submit your claim form and medical records within one year of the service date. See the Out-of-area services section in the Other important information about your plan section for more information on claims for Emergency or Urgent Services outside of California. Your coverage This section explains eligibility and enrollment for this plan. It also describes the terms of your coverage, including information about effective dates and the different ways your coverage can end. Eligibility for this plan To be eligible for coverage as a Subscriber, you must meet all of your Employer’s eligibility requirements and complete any waiting period established by your Employer. Dependent eligibility To be eligible for coverage as a Dependent, you must: •  Be listed on the enrollment form completed by the Subscriber; and •  Be the Subscriber’s spouse, Domestic Partner, or be under age 26 and the child of the Subscriber, spouse, or Domestic Partner. o For the Subscriber’s spouse to be eligible for this plan, the Subscriber and spouse must not be legally separated. o For the Subscriber’s Domestic Partner to be eligible for this plan, the Subscriber and Domestic Partner must have must:  Both be 18 years of age or older;  Share an intimate and committed relationship of mutual caring and a common residence;  Not be married or so closely related by blood that legal marriage or registered domestic partnership (except as otherwise permitted by your Employer)is prohibited; and  Both be mentally competent to consent to a contract when their domestic partnership began. o “Child” includes a stepchild, newborn, child placed for adoption, child placed in xxxxxx care, and child for whom the Subscriber, spouse, or Domestic Partner is the legal guardian. It does not include a grandchild unless the Subscriber, spouse, or Domestic Partner has adopted or is the legal guardian of the grandchild.

Claims for Emergency or Urgent Services. If you receive Emergency or Urgent Services from a Non-Participating Provider, you may be required to pay the charges in full and submit a claim to Blue Shield to request reimbursement. Blue Shield may send the payment to the Subscriber or directly to the Non-Participating Provider. Claim forms are available at xxxxxxxxxxxx.xxx. Please submit your claim form and medical records within one year of the service date. See the Out-of-area services section in the Other important information about your plan section for more information on claims for Emergency or Urgent Services outside of California. Your coverage This section explains eligibility and enrollment for this plan. It also describes the terms of your coverage, including information about effective dates and the different ways your coverage can end. Eligibility for this plan To be eligible for coverage as a Subscriber, you must meet all of your Employer’s eligibility requirements and complete any waiting period established by your Employer. Dependent eligibility To be eligible for coverage as a Dependent, you must: • Be listed on the enrollment form completed by the Subscriber; and • Be the Subscriber’s spouse, Domestic Partner, or be under age 26 and the child of the Subscriber, spouse, or Domestic Partner. o For the Subscriber’s spouse to be eligible for this plan, the Subscriber and spouse must not be legally separated. o For the Subscriber’s Domestic Partner to be eligible for this plan, the Subscriber and Domestic Partner must have must: ▪ Both be 18 years of age or older; ▪ Share an intimate and committed relationship of mutual caring and a common residence; ▪ Not be married or so closely related by blood that legal marriage or registered domestic partnership (except as otherwise permitted by your Employer)is prohibited; and ▪ Both be mentally competent to consent to a contract when their domestic partnership began. o “Child” includes a stepchild, newborn, child placed for adoption, child placed in xxxxxx care, and child for whom the Subscriber, spouse, or Domestic Partner is the legal guardian. It does not include a grandchild unless the Subscriber, spouse, or Domestic Partner has adopted or is the legal guardian of the grandchild.

Claims for Emergency or Urgent Services. If you receive Emergency or Urgent Services from a Non-Participating Provider, you may be required to pay the charges in full and submit a claim to Blue Shield to request reimbursement. Blue Shield may send the payment to the Subscriber or directly to the Non-Participating Provider. Claim forms are available at xxxxxxxxxxxx.xxx. Please submit your claim form and medical records within one year of the service date. See the Out-of-area services section in the Other important information about your plan section for more information on claims for Emergency or Urgent Services outside of California. Your coverage This section explains eligibility and enrollment for this plan. It also describes the terms of your coverage, including information about effective dates and the different ways your coverage can end. Eligibility for this plan To be eligible for coverage as a Subscriber, you must meet all of your Employer’s eligibility requirements and complete any waiting period established by your Employer. Dependent eligibility To be eligible for coverage as a Dependent, you must: •  Be listed on the enrollment form completed by the Subscriber; and •  Be the Subscriber’s spouse, Domestic Partner, or be under age 26 and the child of the Subscriber, spouse, or Domestic Partner. o For the Subscriber’s spouse to be eligible for this plan, the Subscriber and spouse must not be legally separated. o For the Subscriber’s Domestic Partner to be eligible for this plan, the Subscriber and Domestic Partner must have a registered domestic partnership (except as otherwise permitted by your Employer). o “Child” includes a stepchild, newborn, child placed for adoption, child placed in xxxxxx care, and child for whom the Subscriber, spouse, or Domestic Partner is the legal guardian. It does not include a grandchild unless the Subscriber, spouse, or Domestic Partner has adopted or is the legal guardian of the grandchild.