What Are Urgent Services?
Urgent services are defined as those covered services (other than emergency services) which are medically necessary to prevent serious deterioration of your health, alleviate serious pain, or treat an unforeseen illness, injury or medical condition.
For example, urgent care is needed when a condition requires prompt medical attention -- usually within 24 hours -- to avoid complications and unnecessary suffering, such as high fever or persistent diarrhea, and to keep the condition from becoming a serious health problem.
Accessing Urgent Care Using Your HMO Option
You are covered for urgent care anywhere in world, but if you want to be covered under your HMO option when you are in California, you must contact your primary care physician.
Your primary care physician has telephone access available 24 hours a day, seven days a week. However, if you have difficulty reaching your primary care physician when you need urgent care in California, call Member Services at the number on your Blue Shield ID card.
Urgent care delivered by your primary care physician is available under the HMO option by paying a copayment.
Accessing Urgent Care Using Your PPO Option
If you obtain urgent care in California without contacting your primary care physician, that care will be covered under your PPO option.
When you receive urgent care in California under your PPO option, it is covered the same as non-preventive, non-emergency care.
If you need urgent care after regular physician office hours, you may want to go to an urgent care center within our preferred network.
You can locate the closest preferred (network) urgent care facility three ways:
When You Need Urgent Care Outside of California and Beyond the United States
Urgent and emergency services outside of the United States are covered through the BlueCard program. You can locate a BlueCard provider with Find a Doctor or by calling (800) 810-BLUE (2583).
We recommend bringing a list of BlueCard providers to your travel destination, rather than waiting until you need urgent care. And you should always travel with your Blue Shield ID card because it contains information that a BlueCard provider will need.
Once you've received services from a BlueCard provider, you will be sent an Explanation of Benefits showing your payment responsibility.
In instances when a BlueCard provider is unavailable, and you receive urgent care from a provider who is not in the BlueCard network, you'll need to submit a claim to Blue Shield of California within one year of the month that you receive those services. We will make a coverage decision within 30 days of receiving your claim.
If you access care from a provider who is not in the BlueCard network, your coverage is at the non-preferred level outlined in your Evidence of Coverage, and you are responsible for any charges over Blue Shield's allowed amount.
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.