Special Circumstances

Emergency Care

In the event of a medical emergency, emergency room care is covered wherever it is received. It may be necessary to call 911 for immediate medical care for your emergency situation. Please contact your primary care practitioner (PCP) as soon as possible to arrange for any necessary follow-up care.

If you are seen in the emergency room, and then admitted to the hospital, you must notify us within 48 hours of being medically able. Please call us locally at (920) 490-6900 or toll-free at 1-888-711-1444. A medical emergency is a condition that manifests itself by acute symptoms of sufficient severity that would lead a prudent layperson who possesses an average knowledge of health and medicine to reasonably conclude that a lack of immediate medical attention will likely result in any of the following:

  • Serious jeopardy to the person’s health, or with respect to a pregnant woman, serious jeopardy to the health of the woman or her unborn child,
  • Serious impairment to the person’s bodily functions, or
  • Serious dysfunction of one or more of the person’s body organs or parts.

Examples of emergency conditions include, but are not limited to, loss of consciousness, severe burns, severe pain, heavy bleeding, and possible heart attack. For emergency conditions that occur in our service area, access the closest in-network hospital emergency facility. When out of our service area, access the closest hospital emergency facility. Please be certain to arrange follow-up care through your PCP.

Covered expenses for emergency care received from a non-participating provider are limited to the amounts that we determine as being usual and customary.

Please contact your PCP prior to non-emergency care which may be rendered in an emergency or urgent care setting.