In an emergency:
1. Call 911 and get the care you need from the nearest provider or hospital emergency room (ER), regardless of whether it is in-network or out-of-network and whether you have the PPO or EPO medical coverage option.
2. Within 48 hours of an inpatient emergency admission — whether for physical illness or injury or behavioral health or substance use disorder treatment — notify Highmark at 888-835-2959 to certify your stay and maximize your benefits.
If you go to an ER and are admitted to an out-of-network hospital or other facility, once the emergency is addressed, you may need to transfer to a network provider.
For emergency services, the Medical Plan pays 80 percent of covered charges after the deductible is met. In all instances, the member is responsible for the deductible and copayments for network care.
The Medical Plan’s payment of charges by physicians and other providers is based on the contracted rate in the area for each procedure or service. If the physician or provider is not in network, benefits are paid based on the contracted rate and members may be billed by the physician or provider for the balance.
Alternatives to the ER
Consider alternatives to a hospital emergency room if you feel taking the time to examine your options will not put your health at risk. Other sources of medical care are
- primary care physicians;
- Highmark’s 24-hour nurse line (888-835-2959);
- the telemedicine benefit provided by Teladoc through Highmark (800-835-2362);
- urgent care centers;
- retail medical clinics (typically in a pharmacy).
Note: Admission to behavioral care and substance use disorder programs and facilities must be pre-certified.
See Guide to Your Healthcare Benefits for more information.