HealthyBlue 2.0/HealthyBlue Advantage Member ... - CareFirst

Emergency and Urgent CareWhen you have a medical emergency, your healthcare coverage isn’t the first thought that comesto mind. We encourage you to become familiarwith this section so you’ll know how to get themaximum benefits available under the plan ifyou should have a medical emergency.All medically necessary emergency and urgentcare will be covered at the In-Network benefitlevel regardless of the provider.MEDICAL EMERGENCIESIf the situation is a medical emergency:Call 911orGo directly to the nearestemergency facilityEmergency Services means, with respect toan Emergency Medical Condition:A. A medical screening examination (asrequired under section 1867 of the SocialSecurity Act, 42 U.S.C. 1395dd) that iswithin the capability of the emergencydepartment of a hospital, includingancillary services routinely available tothe emergency department to evaluatesuch Emergency Medical Condition; andB. Such further medical examination andtreatment, to the extent they are withinthe capability of the staff and facilitiesavailable at the hospital, as are requiredunder section 1867 of the Social SecurityAct (42 U.S.C. 1395dd(e)(3)).Emergency Medical Condition means thesudden and unexpected onset of a medicalcondition of sufficient severity, including severepain, when the absence of immediate medicalattention could reasonably be expected by aprudent layperson who possesses an averageknowledge of health and medicine to result in:➤ Serious jeopardy to the mental orphysical health of the individual; or➤ Danger of serious impairment of theindividual’s bodily functions; or➤ Serious dysfunction of any of theindividual’s bodily organs or parts; or➤ In the case of a pregnant woman,serious jeopardy to the health ofthe fetus.URGENT CAREAn “Urgent Condition” is a condition thatis not a threat to life or limb, but doesrequire prompt medical attention. If thesituation is urgent:➤ Contact your PCP. If your PCP isunavailable or if you are unsure aboutthe meaning or seriousness of thesymptoms, you can call FirstHelp at(800) 535-9700 for medical advice.➤ Go directly to an urgent care center.A list of participating CareFirstBlueChoice Urgent Care Centers canbe found in the CareFirst BlueChoiceProvider Directory or on our website atwww.carefirst.com/doctor. Additionally,if you have any of the HealthyBlueAdvantage plans, you have access toBlueCard ® PPO urgent care facilitiesoutside of the CareFirst BlueChoiceService Area (MD, DC and No. VA).Urgent Care CentersUrgent care centers are walk-in medical facilitiesequipped to handle minor emergencies. Mosturgent care centers have evening and weekendhours if a condition requires immediate attentionand you’re unable to reach your PCP. Urgent carecenters are typically more conveniently locatedand often allow you to be seen more quickly thanin an emergency room. You may refer to the list ofurgent care centers in your CareFirst BlueChoiceProvider Directory or call FirstHelp , toll-freeat (800) 535-9700 for a participating urgent carecenter near you.Follow-Up CareIf your condition requires follow-up care after yourinitial visit to an urgent care center or hospitalemergency room, you should contact your PCP.In-Network benefits may not be available forfollow-up care performed in an urgent care centeror hospital emergency related to the initialcondition.You can always refer to your Evidence ofCoverage/Agreement or contact Member Servicesto determine whether you’re following the correctprocedures to receive the highest level of benefits.REMEMBER:Prior authorizationis not needed foremergency roomservices.Urgent care centersdo not take theplace of your PCP.Your PCP should beyour first contactwhenever you needmedical care.HealthyBlue Member Handbook15