2025 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(d). Emergency Services/Accidents
Page 78
Section 5(d). Emergency Services/Accidents
Page 78
Note: We state whether or not the calendar year deductible applies for each benefit listed in this section.
Benefit Description
Accidental Injury
When you receive care for your accidental injury within 72 hours of the injury, we cover:
Notes:
You Pay
Preferred: Nothing (no deductible)
Participating: Nothing (no deductible)
Non-participating: Nothing (no deductible)
Non-preferred facilities (Member/Non-member):
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
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, 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 centers licensed as and permitted to provide emergency 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.
- The urgent care center must be licensed and permitted to provide emergency services in order to receive protections under the NSA. See Section 4.
- See Section 5(g) for dental benefits for accidental injury.
You Pay
Preferred: Nothing (no deductible)
Participating: Nothing (no deductible)
Non-participating: Nothing (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
Professional provider services in the provider's office, including, diagnostic studies, radiology services, laboratory tests, and pathology services, when billed by a professional provider.
You Pay
Preferred: Nothing (no deductible)
Participating: Nothing (no deductible)
Non-participating: Any difference between our allowance and the billed amount (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.
Professional provider services in the provider's office, including, diagnostic studies, radiology services, laboratory tests, and pathology services, when billed by a professional provider.
You Pay
Preferred: Nothing (no deductible)
Participating: Nothing (no deductible)
Non-participating: Any difference between our allowance and the billed amount (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 and inpatient professional care you receive is covered regardless of the hospital’s or professional provider’s network status.
Notes:
You Pay
30% of the Plan allowance (deductible applies)
Note: In certain circumstance you may be responsible for any difference between our allowance and the billed amount for care you receive from Non-member facilities. See Section 4 for more information on your protections against balance billing from Non-participating providers.
When you are admitted to the hospital within 72 hours of an accidental injury, your inpatient admission and inpatient professional care you receive is covered regardless of the hospital’s or professional provider’s network status.
Notes:
- See Section 5(a) for inpatient professional services.
- 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 coverage.
- See Section 4 for your protections against balance billing from Non-participating providers.
- For more information regarding non-participating provider exceptions, see Section 3.
You Pay
30% of the Plan allowance (deductible applies)
Note: In certain circumstance you may be responsible for any difference between our allowance and the billed amount for care you receive from Non-member facilities. See Section 4 for more information on your protections against balance billing from Non-participating providers.
Accidental Injury - continued on next page