Emergency, Urgent and Follow-Up Care

What are Emergency Services?   |   What is Urgent Care?   |   What is Follow-Up Care?
Urgent Care and Follow-Up Care Outside Keystone’s Service Area —
The BlueCard® Program’s Urgent and Follow-Up Care Benefits

What are Emergency Services?

“Emergency Services” are any health care services provided to a child after the sudden onset of a medical condition. The condition manifests itself by acute symptoms of sufficient severity or severe pain, such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

	A.		placing the health of the child or with respect to a pregnant adolescent, the health of the adolescent or her unborn child, in serious jeopardy;
	B.		serious impairment to bodily functions; or
	C.		serious dysfunction of any bodily organ or part. Emergency transportation and related emergency services provided by a licensed ambulance service shall constitute an emergency service.

Emergency Services Inside and Outside the Service Area
Emergency services are covered whether they are provided inside or outside Keystone’s service area. Emergency services do not require a referral for treatment from your child’s primary care physician. You must notify your child’s primary care physician to coordinate all continuing care. Medically necessary care by any provider other than your child’s primary care physician will be covered until he or she can, without medically harmful consequences, be transferred to the care of his or her primary care physician or a referred specialist.

Examples of conditions requiring emergency services are:

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

Medical Screening Evaluation
Medical screening evaluation services are covered services when performed in a hospital emergency department to determine whether or not an emergency exists.

	NOTE: Emergency services do not require a referral for treatment from the primary care physician. If you believe your child needs emergency services, you should call 911 or go immediately to the emergency department of the closest hospital. Coverage of reasonably necessary costs associated with emergency services provided during the period of the emergency are covered by this plan.