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:
- Placing your health in serious jeopardy
- Serious impairment to bodily functions
- Serious dysfunction of any bodily organ or part.
In other words, emergencies are situations where immediate medical attention is required to prevent death or disability due to a sudden trauma or illness (e.g., a stroke, severe pain or an acute mental health episode).
Accessing emergency care
You are covered for emergency care anywhere in the world, and the higher copayments associated with Affiliate provider designations don't apply to emergency care. Your emergency care is covered at the Choice provider level.
For more information about Choice and Affiliate hospitals in our network choice program, see How We Classify Hospitals.
For emergency room visits that result in direct admission to the hospital, you or a family member must notify Blue Shield - or our mental health services administrator (MHSA) - within:
- 24 hours of receiving inpatient emergency care
- By the end of the first business day following treatment
- As soon as it is medically possible to notify us
If it is determined that a reasonable person would not have believed that the condition represented an emergency, your coverage for services you received will depend on whether you accessed care from a Choice hospital, an Affiliate hospital, or a hospital that is not in our network.
In this case, Blue Shield will notify you of its coverage decision within 30 to 45 days of receiving the complete claim.
Emergency care outside of the United States
In an emergency, you should always seek care at the nearest medical facility. You are not required to use the BlueCard program or the Blue Shield Global Core network for emergency care.