Currentblue cross blue shield - michiganPolicy N/A

Worldwide Emergency and Urgent Care and Emergency Transportation Coverage

This policy governs coverage, reimbursement, member cost sharing, and member reimbursement procedures for emergency and urgent health care services and emergency transportation rendered outside the United States for BCN Advantage Medicare Advantage members (group and individual) and select group plans.

Policy Summary

Payerblue cross blue shield - michigan

PolicyWorldwide Emergency and Urgent Care and Emergency Transportation Coverage

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionIf coverage is uncertain, providers should obtain a coverage determination from BCN Advantage before providing noncovered items and submit member reimbursement claims for foreign services requiring currency conversion through Blue Cross Blue Shield Global Core.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

$50,000combined lifetime maximum benefit for worldwide emergency/urgent services (some plans)

$130typical worldwide emergency care member cost share

$45typical worldwide urgent care member cost share

BCBS Global Coreclaims submission pathway for foreign services requiring currency conversion

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Worldwide Emergency and Urgent Care Coverage

Coverage criteria and operational rules

Covered when ALL of the following apply:

Coverage applies to BCN Advantage group and individual members and select group plans as an enhanced Medicare Advantage benefit where Original Medicare does not provide coverage

Services are worldwide emergency or urgently needed health care services, or emergency transportation, rendered outside of the United States or its territories

ALL of the following

Emergency medical condition: acute symptoms of sufficient severity that a prudent layperson could reasonably expect absence of immediate attention to result in serious jeopardy to health, serious impairment to bodily functions, or serious dysfunction of any bodily part (including risks to a pregnant woman or her unborn child)
Urgent care: services that are not emergency services but are medically necessary and require immediate attention as a result of an unforeseen illness, injury or condition

Coverage is subject to plan-specific terms, limits, and cost-sharing; BCN Advantage determines reimbursement methodology, maximum allowable payments, and member cost sharing for this enhanced benefit

Plan limits

Some individual BCN Advantage plans and select group plans: combined $50,000 lifetime maximum for worldwide emergency/urgent services and emergency transportation
Some BCN Advantage group plans: may have no maximum coverage amount for emergent or urgently needed services furnished outside the United States and its territories

In-network cost share applies for BCN Advantage HMO-POS members who seek worldwide emergency or urgent care or emergency transportation

Member and provider responsibilities and operational notes: providers should verify member eligibility and plan-specific terms; if coverage is uncertain obtain a coverage determination from BCN Advantage before providing noncovered items; members with foreign-service claims requiring currency conversion or interpretation must submit required documentation through Blue Cross Blue Shield Global Core as directed by BCN Advantage

Provider liability: providers may not require members to sign an Advanced Beneficiary Notice (ABN) for noncovered items when prior coverage determination was not obtained; providers who furnish noncovered items without prior determination must hold the member harmless except for applicable plan cost share per BCN Advantage rules

Reimbursement Basis and Financial Details

Reimbursement basismixed

No codes listed

Financial limits and member cost share examples

Combined lifetime maximumSome individual and select BCN Advantage group plans: $50,000 combined lifetime maximum for worldwide emergency and urgently needed services and emergency transportation

Typical emergency care member cost shareElements/Classic/Prestige/Prime Value/Connected Care (individual plans): $130 per event

Typical urgent care member cost shareElements/Prime Value/Connected Care: $45; Classic: $40; Prestige: $35

Emergency transportation member cost shareElements: $300; Classic: $250; Prestige: $250; Prime Value: $310; Connected Care: $230

In-network cost sharing ruleIn-network cost share applies for BCN Advantage HMO-POS members who seek worldwide emergency or urgent care or emergency transportation

Prior Determination and Claim Submission

Prior Authorization

Obtain coverage determination and follow BCBS Global Core routing for foreign claims

If there is any question about whether an item is covered, obtain a coverage determination from BCN Advantage before providing noncovered items. Providers may not have members sign an Advance Beneficiary Notice of Noncoverage (ABN) to accept financial responsibility for noncovered items; if a provider issues a noncovered item without first obtaining a coverage determination, the member must be held harmless for all charges except any applicable cost share. For member reimbursement of foreign services (including those requiring currency conversion or interpretation) submit invoices and a BCBSGC International Claim Form to Blue Cross Blue Shield Global Core per the instructions on the form; services on cruise ships that do not require interpretation or currency conversion may be submitted directly to Blue Cross using the BCN Advantage medical claim form.

Seek BCN Advantage coverage determination when coverage is uncertain before providing noncovered items (providers may not have members sign ABNs).
If noncovered items are provided without a prior determination, the member must be held harmless for all charges except applicable cost share.
For foreign services requiring currency conversion/interpretation, submit invoices and the BCBSGC International Claim Form to the BCBSGC Service Center as directed on the form.
Cruise-ship services that do not require currency conversion/interpretation may be submitted directly to Blue Cross using the BCN Advantage medical claim form.
Member reimbursement submissions must include member name, BCN Advantage contract and group numbers, address, itemized bills with provider name/address, dates of service, diagnosis, description and charges per service, and paid receipts.

Key Definitions

Emergency medical condition

DefinitionAn emergency medical condition is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson...could reasonably expect the absence of immediate medical attention to result in: serious jeopardy to health (or the health of a pregnant woman or her unborn child); serious impairment to bodily functions; or serious dysfunction of any bodily part.

ApplicabilityUsed to determine coverage for worldwide emergency services and emergency transportation under BCN Advantage enhanced benefits

Medicare contextOriginal Medicare does not cover emergent or urgently needed services furnished outside the U.S.; BCN Advantage defines scope and reimbursement for these emergency medical conditions

Urgent care

DefinitionUrgent care includes services that are not emergency services but are medically necessary and require immediate attention as a result of an unforeseen illness, injury or condition.