Out-of-Network Emergency Services

You will not be responsible for the costs of “emergency services” you receive in a hospital, other than any in-network cost-sharing (in-network copay, coinsurance and/or deductible) that applies to such services under your plan. This is true even if:

  • You receive the emergency services at an out-of-network hospital, or
  • An out-of-network provider provides you services during an emergency hospital visit.

What are emergency services?

Emergency services generally refer to the following hospital services to treat an emergency condition:

  • Medical screening exams that a hospital’s emergency department can perform, including ancillary services routinely used to assess emergency medical conditions, and
  • Additional medical exams and treatment required to stabilize a patient.

An emergency condition means a medical or behavioral condition that produces symptoms serious enough to qualify it as an emergency condition. An example is if you have severe pain that you know could result in one or more of the following without getting immediate medical attention:

  • Extreme danger to the health of the person experiencing the emergency condition, or a behavioral condition
  • Serious impairment to the bodily functions of the affected person
  • Serious dysfunction of any bodily organ or part of the affected person
  • Serious disfigurement of the affected person

What are some examples?

Here are examples of times you would be responsible only for the in-network cost-sharing for out-of-network emergency services:

  • You go to an in-network hospital emergency department and an out-of-network physician is brought in to perform services to treat the emergency condition
  • An ambulance takes you to an out-of-network hospital and you receive emergency services at that out-of-network hospital

Here are examples of times these protections would not apply:*

  • You receive services from a provider at an out-of-network urgent care center, rather than in a hospital
  • You receive services in a hospital that do not qualify as emergency services, according to the above definition of emergency services

How does Carelon Behavioral Health process claims for out-of-network emergency services?

If Carelon Behavioral Health receives a claim for emergency services from an out-of-network provider, we’ll pay the claim at the amount we determine to be reasonable for the emergency services — except for any in-network cost-sharing (in-network copay, coinsurance and/or deductible) that applies under your plan.

If we pay an amount less than what the out-of-network provider charges, Carelon Behavioral Health will send you a notice — either within, or together with, your Explanation of Benefits — explaining that:

  • Your out-of-pocket costs for the emergency services won’t be any higher than if you’d received them from an in-network provider,
  • Your cost-sharing for the emergency services may increase if an IDRE (independent dispute resolution entity) decides Carelon Behavioral Health must pay an additional amount(s) for physician services, and
  • You should contact Carelon Behavioral Health if the out-of-network provider bills you for the out-of-network emergency services for amounts greater than your in-network cost-sharing for the services. For instructions, scroll down to “What to Do If You Get a Bill for Out-of-Network Emergency Services or Surprise Bills.”