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2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Page 80

Benefit Description

Inpatient Hospital (cont.)

Note: Observation services are billed as outpatient facility care. As a result, benefits for observation services are provided at the outpatient facility benefit levels described on page 82. See page 155 for more information about these types of services.

Note: Here are some things to keep in mind:

You do not need to precertify your delivery; see page 26 for other circumstances, such as extended stays for you or your newborn.
If you need to stay longer in the hospital than initially planned, we will cover an extended stay if it is medically necessary. However, you must precertify the extended stay. See page 26 for information on requesting additional days.
We pay inpatient hospital benefits for an admission in connection with the treatment of children up to age 22 with severe dental caries. We cover hospitalization for other types of dental procedures only when a non-dental physical impairment exists that makes hospitalization necessary to safeguard the health of the patient. We provide benefits for dental procedures as shown in Section 5(g).

Note: See pages 47-48 for other covered maternity services.

Note: See page 59 for coverage of blood and blood products.

Note: For certain surgical procedures, your out-of-pocket costs for facility services are reduced if you use a facility designated as a Blue Distinction Center. See pages 86-87 for information.

Standard Option - You Pay
See previous page

Basic Option - You Pay
See previous page

Benefit Description

Not covered:

Admission to noncovered facilities, such as nursing homes, extended care facilities, schools, or residential treatment centers (except as described on pages 87-88 and 100-101)
Personal comfort items, such as guest meals and beds, phone, television, beauty and barber services
Private duty nursing
Facility room and board expenses when, in our judgment, an admission or portion of an admission is:
- Custodial or long term care (see Definitions)
- Convalescent care or a rest cure
- Domiciliary care provided because care in the home is not available or is unsuitable

Standard Option - You Pay
All charges

Basic Option - You Pay
All charges

Inpatient Hospital - continued on next page

Go to page 79. Go to page 81.