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Use of Emergency Room Services
SmartHealth defines a medical emergency as “severe symptoms which occur suddenly and unexpectedly, and if treatment is not rendered within the first 48 hours of onset, could cause serious harm to bodily functions or even death.” Emergency room services are not appropriate for 1) conditions that have been present for a number of days and have not suddenly worsened and 2) conditions that are neither life threatening nor permanently damaging.
The following chart gives a partial list of common illnesses and that are not appropriate for emergency room (ER) services.
Not Appropriate for ER Services |
Sore throat |
Cold or flu |
Rash |
Toothache |
A co-payment must be paid at the time emergency room services are rendered for any SmartHealth member. The co-payment is waived if a member is admitted to the hospital for inpatient treatment. The co-payment for urgent care or a visit to your physician’s office is considerably less:
Service |
Tier 1 |
Tier 2 |
Emergency Room |
$100 |
$125 |
Urgent Care |
$20 |
$40 |
Physician Office |
$15 PCP |
$20 PCP |
The appropriate use of ER services is very important for many reasons:
- The average cost of an ER visit for SmartHealth medical-enrolled members is over $850, driving up health care costs that could increase the cost of your health care.
- Use of the emergency room for routine, non-emergency medical care increases the wait times for everyone waiting to be seen in an emergency room.
- Routine, non-emergency care provided by your physician provides continuity in your care since your physician knows the medical services you need and have already received.
What are your alternatives to using emergency room services?
- Choose a physician from the list of SmartHealth participants found on the internet at
http://smarthealth-mi.org or
http://www.bcbsm.com/home/where_you_can_go_for_care/physicians.shtml
- Seek care from one of the After Hours or Urgent Care Centers listed on the
smarthealth-mi.org Web site or http://www.bcbsm.com/home/where_you_can_go_for_care/urgent_care.shtml
Questions regarding your medical benefits should be directed to 888-492-6811.