Diagnostic X-Ray and Other Imaging Tests
Part 3 Emergency Services
Post-Stabilization Care
After your emergency medical condition has been evaluated and stabilized in the hospital emergency room, youmay be ready to go home. Or, you may require further care. Blue Cross and Blue Shield will consider post-stabilization covered services to be approved if an approval is not given within 30 minutes of the emergency room provider’s call. If the emergency room provider and your health care provider do not agree as to the right medical treatment for you, your health plan will cover the health care services and supplies that are recommended by the emergency room provider. But, benefits will be provided only for the health care services and supplies that are covered by your health plan.
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Admissions From the Emergency Room. Your condition may require that you be admitted directly from the emergency room into that hospital for inpatientemergency medical care. If this happens, you or the admitting facility (or someone on your behalf) must call Blue Cross and Blue Shield. (A health care facility that participates in your health care network should call Blue Cross and Blue Shield for you.) This call must be made within 48 hours of your admission. This call must include: your name; your ID number; the name of the health care facility; the date of admission; and the condition for which you are receiving treatment. This is required so that Blue Cross and Blue Shieldcan evaluate and monitor the appropriateness of your inpatient health care services.
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Transfers to Other Inpatient Facilities. Your emergency room provider may recommend your transfer to another facility for inpatient care. If this happens, you or the admitting facility (or someone on your behalf) must call Blue Cross and Blue Shield. (A health care facility that participates in your health care network should call Blue Cross and Blue Shield for you.) This call must be made within 48 hours of your admission. This is required so that Blue Cross and Blue Shield can evaluate the appropriateness of the inpatient health care services.•
Outpatient Follow Up Care. Your emergency room provider may recommend that you haveoutpatient follow up care. If this happens, the emergency room provider must call Blue Cross and Blue Shield to obtain an approval when the type of care that you need requires an approval from Blue Cross and Blue Shield. (See Part 4.) If you need to have more follow up care and an approval is required, you or your health care provider must obtain the approval from Blue Cross and Blue Shield.
WORDS IN ITALICS ARE EXPLAINED IN PART 2.
Part 4
Utilization Review Requirements
To receive all of the coverage provided by your health plan, you must follow all of the requirements described in this section. Your coverage may be denied if you do not follow these requirements.
Pre-Service Approval Requirements
There are certain health care services or supplies that must be approved for you by Blue Cross and Blue Shield. A health care provider who participates in your health care network should request a pre-service approval on your behalf. (You must request this review if the health care provider does not start the process for you.) For the pre-service review, Blue Cross and Blue Shield will consider your health care provider to be your authorized representative. Blue Cross and Blue Shield will tell you and your health care provider if coverage for a proposed service has been approved or if coverage has been denied. To check on the status of a request or to check for the outcome of a utilization review decision, you can call your health care provider or the Blue Cross and Blue Shield customer service office. The toll free phone number to call is shown on your ID card. Remember, you should check with your health care provider before you receive services or supplies to make sure that your health care providerhas received approval from Blue Cross and Blue Shield when a pre-service approval is required. Otherwise, you will have to pay all charges for those health care services and/or supplies.
(The requirements described below in this part do not apply to your covered services when Medicare is the primary coverage.)
Referrals for Specialty Care
You do not need a referral from your primary care provider or your attending physician in order for you to receive your health plan coverage. But, there are certain health care services and supplies that must be approved by Blue Cross and Blue Shield before you receive them. (See below.)
Pre-Service Review for Outpatient Services
To receive all of your coverage for certain outpatient health services and supplies, you must obtain a pre-service approval from Blue Cross and Blue Shield. A health care provider who participates in your health care network will request this approval on your behalf. During the pre-service review, Blue Cross and Blue Shield will determine if your proposed health care services or supplies should be covered as
medically necessary for your condition. Blue Cross and Blue Shield will make this decision within two working days of the date that it receives all of the needed information from your health care provider. You must receive a pre-service approval from Blue Cross and Blue Shield for: