Emergency Room Benefits. Benefits are provided for Emergency Services provided in the emergency room of a Hospital. For the lowest out-of-pocket expenses, covered non- Emergency Services and emergency room follow- up services (e.g., suture removal, wound check, etc.) should be received in a Participating Physician’s office. Emergency Services are services provided for an unexpected medical condition, including a psychiatric emergency medical condition, manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) placing the Member’s health in serious jeopardy; (2) serious impairment to bodily functions; (3) serious dysfunction of any bodily organ or part.
Emergency Room Benefits. Benefits are provided for Medically Necessary Services pro- vided in the Emergency Room of a Hospital. For the lowest out-of-pocket expenses covered non-emergency Services or emergency room follow-up Services (e.g., suture removal, wound check, etc.) should be received in a Participating Phy- sician’s office. Emergency Services are Services provided for an unexpected medical condition, including a psychiatric emergency medi- cal condition, manifesting itself by acute symptoms of suffi- cient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) placing the Member’s health in serious jeopardy; (2) serious impairment to bodily functions; (3) serious dysfunction of any bodily organ or part. Note: Emergency Room Services resulting in an admission to a Non-Preferred Hospital which the Plan determines are not emergencies will be paid as part of the Inpatient Hospital Services. The Subscriber Copayment for non-emergency Inpatient Hospital Services from a Non-Preferred Hospital is shown in the Summary of Benefits. For Emergency Room Services directly resulting in an ad- mission to a different Hospital, the Subscriber is responsible for the emergency room Subscriber Copayment plus the ap- propriate admitting Hospital Services Subscriber Copayment as shown in the Summary of Benefits.
Emergency Room Benefits. Emergency room Physician Services Note: After Services have been provided, Blue Shield may conduct a retro- spective review. If this review determines that Services were provided for a medical condition that a person would not have reasonably believed was an emergency medical condition, Benefits will be paid at the applicable Pre- ferred and Non-Preferred Provider levels as specified under Outpatient Physician Services Benefit in the Professional (Physician) Benefits in this Summary of Benefits and will be subject to any Calendar Year medical Deductible. 30% 30% Emergency room Services not resulting in admission Note: After Services have been provided, Blue Shield may conduct a retro- spective review. If this review determines that Services were provided for a medical condition that a person would not have reasonably believed was an emergency medical condition, Benefits will be paid at the applicable Pre- ferred and Non-Preferred Provider levels as specified under Hospital Bene- fits (Facility Services), Outpatient Services for treatment of illness or inju- ry, radiation therapy, chemotherapy and necessary supplies in this Summary of Benefits and will be subject to any Calendar Year medical Deductible. $100 per visit plus 30% $100 per visit plus 30% Emergency room Services resulting in admission (billed as part of Inpa- tient Hospital Services) $250 per admission plus 30% $250 per admission plus 30% 11 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Family Planning Benefits 12 Note: Copayments listed in this section are for Outpatient Physician Services only. If Services are performed at a facility (Hospital, Ambulatory Surgery Center, etc), the facility Copayment listed under the appropriate facility benefit in the Summary of Benefits will also apply. Counseling and consulting (Including Physician office visits for diaphragm fitting or injectable contracep- tives) 30% Not covered Diaphragm fitting procedure When administered in an office location, this is in addition to the Physician office visit Copayment. 30% Not covered Injectable contraceptives When administered in an office location, this is in addition to the Physician office visit Copayment. $25 per injection Not covered Tubal ligation In an Inpatient facility, this Copayment is billed as part of Inpatient Hospital Services for a delivery/abdominal surgery. 30% Not covered Vasectomy 30% Not covered Be...
Emergency Room Benefits. Benefits are provided for Emergency Services provided in the emergency room of a Hospital. Covered non-Emergency Services and emergency room follow-up services within the Primary Care Physician service area (e.g., suture removal, wound check, etc.) must be authorized by Blue Shield or obtained through the Member’s Primary Care Physician. Emergency Services are services provided for an Emergency Medical Condition, including a psy- chiatric Emergency Medical Condition or active labor, manifesting itself by acute symptoms of suf- ficient severity (including severe pain) such that the absence of immediate medical attention could rea- sonably be expected to result in any of the follow- ing: (1) placing the Member’s health in serious jeopardy; (2) serious impairment to bodily func- tions; (3) serious dysfunction of any bodily organ or part. When a Member is admitted to the Hospital for Emergency Services, Blue Shield should receive emergency admission notification within 24 hours or as soon as it is reasonably possible following medi- cal stabilization. The services will be reviewed retro- spectively by Blue Shield to determine whether the services were for an Emergency Medical Condition. Services Provided at a Non-Plan Hospital Following Stabilization of an Emergency Medical Condition When the Member’s Emergency Medical Condition is stabilized, and the treating health care provider at the non-Plan Hospital believes additional Medically Necessary Hospital services are required, the non- Plan Hospital must contact Blue Shield to obtain timely authorization. Blue Shield may authorize con- tinued Medically Necessary Hospital services by the non-Plan Hospital. If Blue Shield determines the Member may be safely transferred to a Hospital that is contracted with the Plan and the Member refuses to consent to the trans- fer, the non-Plan Hospital must provide the Member with written notice that the Member will be xxxxx- cially responsible for 100% of the cost for services provided following stabilization of the Emergency Medical Condition. As a result, the Member may be billed by the non-Plan Hospital. Members should contact Shield Concierge at the number provided on the back page of the EOC for questions regarding im- proper billing for services received from a non-Plan Hospital. For information on Emergency Services received outside of California, see the Inter-Plan Arrange- ments section of the EOC. Family Planning and Infertility Benefits Benefits are provided for th...
Emergency Room Benefits. Benefits are provided for Emergency Services pro- vided in the emergency room of a Hospital. For the lowest out-of-pocket expenses, covered non- Emergency Services and emergency room follow- up services (e.g., suture removal, wound check, etc.) should be received in a Participating Physi- cian’s office. Emergency Services are services provided for an Emergency Medical Condition, including a psy- chiatric Emergency Medical Condition or active labor, manifesting itself by acute symptoms of suf- ficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the fol- lowing:
Emergency Room Benefits. Benefits are provided for Emergency Services provided in the emergency room of a Hospital. Covered non-Emergency Services and emergency room follow-up services within the Primary Care Physician service area (e.g., suture removal, wound check, etc.) must be authorized by Blue Shield or obtained through the Member’s Primary Care Physician. Emergency Services are services provided for an Emergency Medical Condition, including a psy- chiatric Emergency Medical Condition or active labor, manifesting itself by acute symptoms of suf- ficient severity (including severe pain) such that the absence of immediate medical attention could rea- sonably be expected to result in any of the follow- ing: (1) placing the Member’s health in serious jeopardy; (2) serious impairment to bodily func- tions; (3) serious dysfunction of any bodily organ or part. When a Member is admitted to the Hospital for Emergency Services, Blue Shield should receive emergency admission notification within 24 hours or as soon as it is reasonably possible following medi- cal stabilization. The services will be reviewed retro- spectively by Blue Shield to determine whether the Benefits are provided for Infertility services, except as excluded in the Principal Limitations, Exceptions, Exclusions and Reductions section, including profes- sional, Hospital, Ambulatory Surgery Center, and ancillary services to diagnose and treat the cause of Infertility. See also the Preventive Health Benefits section for additional family planning services. services were for an Emergency Medical Condition.
Emergency Room Benefits. Benefits are provided for Emergency Services provided in the emergency room of a Hospital. Covered non-Emergency Services and emergency room follow-up services (e.g., suture removal, wound check, etc.) must be authorized by Blue Shield or obtained through the Member’s Personal Physician. Emergency Services are services provided for an emergency medical condition, including a psy- chiatric emergency medical condition or active la- bor, manifesting itself by acute symptoms of suffi- cient severity (including severe pain) such that the absence of immediate medical attention could rea- sonably be expected to result in any of the follow- ing: (1) placing the Member’s health in serious jeopardy; (2) serious impairment to bodily func- tions; (3) serious dysfunction of any bodily organ or part. When a Member is admitted to the Hospital for Emergency Services, Blue Shield should receive Emergency Admission Notification within 24 hours or as soon as it is reasonably possible following medical stabilization. The services will be reviewed retrospectively by Blue Shield to determine whether the services were for a medical condition for which Family Planning and Infertility Benefits Benefits are provided for the following fam- ily planning services without illness or injury being present:
Emergency Room Benefits. Benefits are provided for Emergency Services pro- vided in the emergency room of a Hospital. For the lowest out-of-pocket expenses, covered non- Emergency Services and emergency room follow- up services (e.g., suture removal, wound check, etc.) should be received in a Participating Physi- cian’s office. Emergency Services are services provided for an emergency medical condition, including a psychi- atric emergency medical condition or active labor, manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the ab- sence of immediate medical attention could rea- sonably be expected to result in any of the follow- ing:
Emergency Room Benefits. Benefits are provided for Emergency Services pro- vided in the emergency room of a Hospital. For the lowest out-of-pocket expenses, covered non- Emergency Services and emergency room follow- up services (e.g., suture removal, wound check, etc.) should be received in a Participating Provider’s office. Emergency Services are services provided for an Emergency Medical Condition, including a psy- chiatric Emergency Medical Condition or active labor, manifesting itself by acute symptoms of suf- ficient severity (including severe pain) such that the absence of immediate medical attention could No Benefits are provided for family planning ser- vices from Non-Participating Providers. See also the Preventive Health Benefits section for additional family planning services. For plans with a Calendar Year Deductible for ser- vices by Participating Providers, the Calendar Year Deductible applies only to male steriliza- tions.
Emergency Room Benefits. Benefits are provided for Medically Necessary Services provided in the Emergency Room of a Hospital. Note: Emergency Room Services resulting in an admission to a Non-Preferred Hospital which Blue Shield determines is not an emergency will be paid as part of the Inpatient Hospital Services. The Subscriber Copayment for non- emergency Inpatient Hospital Services from a Non- Preferred Hospital is shown on the Summary of Benefits. For Emergency Room Services directly resulting in an ad- mission to a different Hospital, the Subscriber is responsible for the Emergency Room Subscriber Copayment plus the appropriate Admitting Hospital Services Subscriber Co- payment as shown on the Summary of Benefits. Family Planning Benefits Benefits are provided for the following Family Planning Services without illness or injury being present. For Family Planning Services, for Plans with a Calendar Year Deductible for Services by Preferred Providers, the Calendar Year Deductible only applies to steriliza- tions/abortions and intrauterine devices (IUDs), including insertion and/or removal. Note: No benefits are provided for Family Planning Ser- vices from Non-Preferred Providers. No Benefits are pro- vided for IUDs when used for non-contraceptive reasons except the removal to treat Medically Necessary Services related to complications.
