Payments Relating to Emergency Services Rendered. The amount We pay a Non-Network Provider for Emergency Services will be the amount We have negotiated with the Non-Network Provider for the Emergency Service or an amount We have determined is reasonable for the Emergency Service. However, the amount negotiated or the amount We determine is reasonable will not exceed the Non-Network Provider’s charge and will be at least the greater of: 1) the amount We have negotiated with Network Providers for the Emergency Service (and if more than one amount is negotiated, the median of the amounts); 2) 100% of the Allowed Amount for services provided by a Non-Network Provider (i.e., the amount We would pay in the absence of any Cost-Sharing that would otherwise apply for services of Non-Network Providers); or 3) the amount that would be paid under Medicare. You are only responsible for any Network Copayment, Deductible or Coinsurance. You are not responsible for any Non-Network Provider charges that exceed Your Copayment, Deductible or Coinsurance.
Payments Relating to Emergency Services Rendered. The amount We pay a Non-Network Provider for Emergency Services will be the amount We have negotiated with the Non-Network Provider for the Emergency Service or an amount We have determined is reasonable for the Emergency Service, less any Copayment, Coinsurance or Deductible. However, the amount We determine is reasonable will not exceed the Non-Network Provider’s charge and will be at least the greater of: 1) the amount We have negotiated with Network Providers for the Emergency Service (and if more than one amount is negotiated, the median of these amounts); 2) the amount for the Emergency Service calculated using the same method Plan generally uses to determine payments for Non-Network Services or 3) the amount that would be paid under Medicare for the Emergency Service. You may be responsible for the difference between the Non-Network Provider’s charge and the amount We determine is reasonable, in addition to any applicable Coinsurance, Copayment or Deductible. Urgent Care Often an urgent rather than an Emergency medical problem exists. All Covered Services obtained at Urgent Care Centers are subject to the Urgent Care Copayment/Coinsurance. If You experience an accidental injury or a medical problem, We will determine whether Your injury or condition is an Urgent Care or Emergency Care situation for coverage purposes, based on Your symptoms. An Urgent Care medical problem is an unexpected episode of illness or an injury requiring treatment which cannot reasonably be postponed for regularly scheduled care. It is not considered an Emergency. Urgent Care medical problems include, but are not limited to, ear ache, sore throat, and fever (not above 104 degrees). Treatment of an Urgent Care medical problem is not life threatening and does not require use of an emergency room at a Hospital. If You call Your Physician prior to receiving care for an urgent medical problem and Your Physician authorizes You to go to an emergency room, Your care will be paid at the level specified in the Schedule of Benefits for Emergency RoomServices. If Urgent Care results in an emergency admission, please follow the instructions for emergency Hospital admissions described above. Allergy Testing We Cover testing and evaluations including injections, and scratch and prick tests to determine the existence of an allergy. We also Cover allergy treatment, including injections and serums.
