Emergency Services Inside and Outside Keystone’s Service Area

Emergency, Urgent and Follow-Up Care

What are Emergency Services? | What is Urgent Care?
Emergency Services Inside and Outside Keystone’s Service Area | Payment for Immediate Care Services | Medical Screening Evaluation | Follow-Up Care Benefits | Auto or Work-Related Accidents

When emergency services are necessary, go immediately to the nearest health care provider or call 911. Notify your primary care physician within 48 hours or as soon as possible.

Examples of conditions requiring emergency services are:

excessive bleeding;
broken bones;
serious burns;
sudden onset of severe chest pain;
sudden onset of acute abdominal pain;
poisoning;
unconsciousness;
convulsions; and
choking.

Coverage of reasonably necessary costs associated with emergency services provided during the period of an emergency are covered by this plan.

Urgent Care Inside Keystone’s Service Area
You are in the service area if you are in Bucks, Chester, Delaware, Montgomery or Philadelphia county.

If you are within the service area and you need urgent care, call your primary care physician first.
If your primary care physician is not in the office, leave a message requesting a return call.
Your primary care physician provides coverage 24 hours a day, 7 days a week for urgent care.
Your primary care physician, or the physician covering for your primary care physician, will arrange for appropriate medically necessary treatment.

Urgent Care and Follow-Up Care Outside Keystone’s Service Area — The BlueCard® Program’s Urgent and Follow-Up Care Benefits

adultBasic members have access to health care services when traveling outside of Keystone’s service area. These services are available through the Blue Cross and Blue Shield Association’s BlueCard Program. Through the BlueCard Program, out of pocket costs are limited to applicable co-payments. The length of time that you will be outside the service area may affect:

	A.		the benefits you receive; or
	B.		the procedures you must follow to obtain care for yourself under adultBasic.

A claim form is not required to be submitted in order for an adultBasic member to receive benefits, provided the member meets the requirements identified below.

Urgent Care Benefits When Traveling Outside Keystone’s Service Area

Urgent care benefits cover medically necessary treatment for any unforeseen illness or injury that requires treatment prior to when you return to Keystone’s service area.

Covered services for urgent care are provided by a contracting Blue Cross and Blue Shield Association traditional participating provider (“BlueCard traditional provider”).
Coverage is for medically necessary services required to prevent serious deterioration of the adultBasic member’s health while traveling outside Keystone’s service area during a temporary absence (less than 90 consecutive days).
After 90 days, the member must return to the Keystone service area or be disenrolled automatically from the Keystone adultBasic program, unless the member is enrolled under a Guest Program registration. More information available.

Urgent care required during a temporary absence will be covered when:

You call 1-800-810-BLUE. This number is available 24 hours a day, 7 days a week. You will be given the names, addresses and phone numbers of three BlueCard traditional providers. The BlueCard Program has some international locations. When you call, you will be asked whether you are inside or outside of the United States.
You decide which provider you will see.
You call 1-800-227-3116 to get prior authorization (approval) for the service from Keystone.
After receiving Keystone’s approval, you call the provider to schedule an appointment. The BlueCard traditional provider confirms member eligibility.
You show your ID Card when seeking services from the BlueCard traditional provider.

Follow-Up Care Benefits When Traveling Outside Keystone’s Service Area

Follow-up care benefits under the BlueCard program cover medically necessary follow-up care required while you are traveling outside of Keystone’s service area.

Follow-up care is provided for urgent ongoing treatment of an injury, illness, or condition that occurred while you were in Keystone’s service area.
Follow-up care must be pre-arranged and preapproved by your primary care physician in Keystone’s service area prior to leaving the service area.
Under the BlueCard Program, coverage is provided only for those specified, preapproved services authorized by your primary care physician in Keystone’s service area and Keystone’s patient care management department.
Follow-up care benefits under the BlueCard Program are available during your temporary absence (less that 90 consecutive days) from Keystone’s service area.

Follow-up care required during a temporary absence (less than 90 consecutive days) from Keystone’s service area will be covered when these steps are followed:

You are currently receiving urgent ongoing treatment for a condition.
You plan to go out of Keystone’s service area temporarily, and your primary care physician recommends that you continue treatment.
Your primary care physician must call 1-800-227-3116 to get prior authorization for the service from Keystone. If a BlueCard traditional provider has not been pre-selected for the follow-up care, your primary care physician or you will be told to call 1-800-810-BLUE.
You or your primary care physician will be given the names, addresses and phone numbers of three BlueCard traditional providers.

When you decide which BlueCard traditional provider you will see:

You or your primary care physician must inform Keystone by calling 1-800-227-3116.
You should call the BlueCard traditional provider to schedule an appointment.
The BlueCard traditional provider confirms your eligibility.
You show your ID Card when seeking services from the BlueCard traditional provider.

Guest Program Benefits

If you plan to travel outside of the Keystone service area for at least ninety (90) consecutive days up to a maximum of 6 consecutive months, and are traveling to an area where a host HMO is located, you are eligible to register as a guest under the BlueCard program’s Guest Program. A 30-day notification period is required before benefits under the Guest Program become available.

NOTE:

The member is required to notify the Caring Foundation at 1-800-464-5437. Notification must be given at least thirty (30) days prior to the member’s scheduled date of departure in order for benefits to be available under the Guest Program.

The Guest Program benefit package provides coverage for a wide range of health care services including hospital care, routine physician visits, and other services. The Guest Program benefits are available only when the member is registered as a guest at a contracting HMO. As a guest, the member is responsible for complying with all the host HMO’s rules regarding access to care and member responsibilities. These rules and responsibilities will be provided by the host HMO at the time of guest registration.

NOTE:

Because the member’s primary care physician can give advice and provide recommendations about health care services that the member may need while traveling, the member is encouraged to receive routine or planned care prior to leaving home.

Participation in the Guest Program requires that the member select a primary care physician from the host HMO’s physician network. In order to receive benefits, the guest primary care physician must provide or arrange for all the member’s covered services while a guest. Neither Keystone nor the host HMO will cover services not provided or arranged by Keystone or the host HMO primary care physician and preapproved by Keystone or the host HMO, except for emergency or urgent care. Guest Program registration is available only through contracting HMOs using the contracted provider network. Not all of the HMOs offering urgent care and follow-up care also offer Guest Program registration. Information regarding the availability of the Guest Program may be obtained by calling the Caring Foundation at 1-800-464-5437.