So What Constitutes a Medical Emergency?

In the choice between P and S networks one of the most common concerns is emergency room care.  We always say, "Never drive past an ER", meaning that you should never think about in and out of network in emergency situations.  Another reason is that emergency care (which is different from emergency room care which could include going on the weekend for the flu) is covered in our medical plan at the same in-network rate at any hospital.

When we give this response the first very reasonable question we get is, "So what is emergency room care to Blue Cross?"  The concern is that a person might go to an out of network hospital thinking something is serious, find out that it isn't, and then be stuck with a big ER bill for out-of-network treatment.

Here, exactly, is the Blue Cross Blue Shield definition for emergency care.

An emergency situation is defined by a "prudent layperson" who possesses an average knowledge of health and medicine, as a medical condition that develops itself by symptoms of sufficient severity, including severe pain.  Failure to provide such treatment could reasonably be expected to result in:
  • Serious impairment of bodily functions
  • Serious dysfunction of a body organ or part
  • Could reasonably be expected to place the person's health in serious jeopardy
  • Threat to the health and safety of a pregnant woman who is having contractions or to an unborn child
  • Danger to self (including psychiatric conditions and intoxication
While there is room for debate after the fact, here are three things for you to consider.  We have had the same possible situation historically with in and out of network ER care before ever going to BCBS.  In ten years of managing the plan we've never had an issue with ER care charged as non-ER care.  Also there is an appeals process and you should use your HR department to help as your advocate if there ever is an issue.  Finally I've reviewed the list of acceptable medical billing codes that count as emergencies and it is 138 pages long.

Remember, if its an emergency go to the nearest ER.  We'll help you sort it out after the fact if there is a problem, but the chances of you having a problem are slim.

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