Highmark, UPMC, and your emergency care.

If I have a Highmark insurance product, can I go to an out-of-network UPMC facility if I have an emergency?

Yes.

For most Commercial products, when there’s an emergency, your Highmark plan covers emergency services at out-of-network facilities at the same member cost-sharing (deductible, coinsurance, or copay) level as in-network facilities with you being held harmless from any balance billing from the out-of-network facility. Once you are considered stable, you should understand your financial impacts should you need to stay at the hospital.

You should always check your plan’s benefits on emergencies to understand your financial liability for emergency services.

How can I find the closest in-network emergency department?

If you believe you are having a medical emergency and you need immediate treatment, go directly to the nearest hospital emergency room or call 911.

To find a hospital or urgent care location that are covered by your insurance, go to https://www.highmarkbcbs.com/find-a-doctor/#/home

You can also download the Highmark app for the closest emergency departments, urgent care centers and more. To get the app, visit your phone’s app store and search for “Highmark”.

Which Pittsburgh and Erie UPMC hospitals will be out-of-network after July 1, 2019?

In the Greater Pittsburgh Area:
• UPMC East
• UPMC Magee-Women’s Hospital
• UPMC McKeesport
• UPMC Mercy
• UPMC Montefiore
• UPMC Passavant (both campuses)
• UPMC Presbyterian
• UPMC St. Margaret
• UPMC Shadyside
• UPMC Hillman Cancer Center at UPMC Shadyside

In Erie:
• UPMC Hamot

Is emergency care at Children’s Hospital considered in-network for Highmark members?

Yes. Emergency care at UPMC Children’s Hospital of Pittsburgh and affiliated doctors and other providers who practice there will be in your network.

If I need emergency care in Erie, can I go to UPMC Hamot?

Yes.

For most Commercial products, when there’s an emergency, your Highmark plan covers emergency services at out-of-network facilities at the same member cost-sharing (deductible, coinsurance, or copay) level as in-network facilities with you being held harmless from any balance billing from the out-of-network facility. You should always check your plan’s benefits on emergencies to understand your financial liability for emergency services.

Once you are considered stable, you should understand your financial impacts should you need to stay at the hospital.

What if I am seen at an out-of-network UPMC Emergency Department and at discharge I am given follow up instructions that include an appointment at UPMC?

Once you are discharged, your post-emergency visit benefits are dependent on the network status of the physician you are referred to. It is best to check if the provider is considered in or out of network with your benefit plan to understand your financial impact.

If you choose to use an out-of-network provider for follow-up care, this link explains how out-of-network benefits work https://faqs.discoverhighmark.com/answers/out-of-network-costs/

If you’d like to obtain follow-up care at an In-Network provider, you should contact your family doctor for assistance. If you need an in-network doctor, please call My Care Navigator to assist you in finding an in-network physician, scheduling your follow up appointment or beginning in-network care. My Care Navigator will assist with transferring your medical records and finding the right provider for your needs.

What if an ambulance takes me to a UPMC out-of-network emergency department when I requested to be taken in-network?

If your request is to be transported to a facility that does not have the right level of care for your emergency or is too far away for your emergent need, the EMS provider may deny your request as your safety is the top priority.

For Commercial products, when there’s an emergency, your Highmark plan covers emergency services at out-of-network facilities at the same member cost-sharing (deductible, coinsurance, or copay) level as in-network facilities with you being held harmless from any balance billing from the out-of-network facility.

Once you are stable, you will have the opportunity to transfer to an in-network facility with the appropriate level of care to remain at an in-network cost. Should you decline to transfer to the in-network facility once stable, your remaining services will be considered out-of-network.

If I need to be transferred to an in-network facility, how will that occur? Is it safe for me?

If needed, your transfer to an in-network facility will be coordinated for you by Highmark with consultation from the physician from the UPMC facility. You will not be transferred until you are deemed stable by your treating physician as your safety is top priority.

We will handle setting up ambulance transportation for you and we will have all necessary medical records transferred to the in-network facility. You will be transported to an in-network facility via ambulance with the appropriate precautions.

Who determines whether or not I am stable for transfer?

Your safety is the first priority. A physician from the out-of-network emergency department is accountable to determine if you are medically stable and appropriate to transfer.

What if I want to stay at the out-of-network hospital where I am admitted through the emergency department? Can I stay there? If so, what will it cost me?

Yes, you can stay at the out-of-network facility after being deemed stable, but you may have significant out-of-pocket costs.

It is important to understand your benefit plan’s out of network coverage, if applicable. Your financial responsibility may be impacted by utilizing an out of network provider.

If you have a plan with out-of-network coverage, you will be responsible for your out-of-network cost-sharing amount plus the difference between Highmark’s allowance and the provider charge. If you do not have a plan with out-of-network coverage, you will be responsible for the total provider charges.

What is “balance billing”?

When a provider bills you for the difference between their charge and the amount that Highmark has agreed to pay, this is referred to as “Balance Billing”.

The Pennsylvania Attorney General has taken action against UPMC. What is the status of his action and will that protect me?

Details on this action are available on the following section of our site: https://faqs.discoverhighmark.com/answers/what-is-actually-happening-with-state-intervention-between-highmark-and-upmc/

Where can I go if I have more questions?

If you have questions regarding your emergency benefits, call My Care Navigator at 1-888-258-3428 for more information.

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