Emergency Medical Transportation Coverage

We want to provide additional clarity on how your health plan covers non-emergent medical transportation particularly in situations where Community Care transports patients from Ashtabula-area hospitals to downtown facilities, including, but not limited to, Cleveland Clinic, Ahuja, and University Hospitals.

Because Community Care is the only transport option available for these transfers, employees are not able to choose an in-network ambulance provider for this situation.

How Emergency Transportation Is Covered

Your health plan covers emergency medical transportation the same way whether the provider is in network or out of network in an emergency situation. This means your deductible, coinsurance, and copay amounts are identical in an emergency, regardless of network status.

However, how the claim is processed depends on how Community Care codes the transport:

• Emergent: Processed under the plan’s emergency transportation benefit.
• Non-emergent: Considered out of network, and out of network cost sharing applies (including the possibility of balance billing).

While the situation may be considered emergent by the provider or facility, if Community Care does not code the transfer as emergent, then additional charges are being applied.

Why You May Receive Higher Bills

Even though emergency cost sharing is the same for in network and out of network emergencies, out of network providers are not required to follow Anthem’s contracted rates in a non-emergent situation. This can result in two different amounts:

• Allowed amount: The amount the plan uses to calculate payment.
• Provider’s billed charge: The amount the provider chooses to charge.

Anthem pays based on the allowed amount. When a provider is out of network, they may bill you for the difference between their charge and the allowed amount. This is known as balance billing, which may lead to higher out of pocket costs.

Because Community Care determines whether the transport is coded as emergent or non-emergent, this coding directly affects whether out of network costs and balance billing apply.

Your Right to Appeal

You have the right to appeal any claim decision that denies or reduces benefits. Your Explanation of Benefits (EOB) will include:

• The reason the claim was denied or adjusted
• Steps for submitting an appeal
• An overview of the appeal process

When filing an appeal, include any information that supports the emergency nature of the situation—such as symptoms, physician documentation, or a timeline of events.

To file an appeal, you may:

• Call the toll free Member Services number on your ID card or the number listed on any adverse decision notice.
• Submit a written appeal by mailing it to:

Anthem Blue Cross and Blue Shield

P.O. Box 105568

Atlanta, GA 30348

(You may also use the address listed on any written denial notice.)

For the most current information about in and out of network service providers, use the Find Care tool on the Sydney ^SM Health app or by log into your account at Anthem.com. Click HERE to learn more about the Sydney ^SM Health app.