Emergency care
When your child needs emergency care, Seton Health Plan covers care at any emergency room in the United States. Your child is covered for emergency care 24 hours a day, seven days a week. In an emergency, take your child to the nearest emergency room for help.
Emergencies include:
- Bleeding that will not stop
- Broken bones
- Loss of consciousness
- Chest pain
- Drug overdose
- Poisoning
- Sudden trouble breathing
After your child receives care, call his or her doctor as soon as possible. Your child's PCP will provide or arrange for any follow-up care. If you get follow-up care from a doctor other than your child's PCP without a referral, Seton Health Plan may not pay for the care.
If you are sure your child's illness or injury is not life threatening but are not sure if he or she needs emergency care, call your child's PCP. You can expect to see his or her PCP on the same day. The PCP will tell you if you should go to the emergency room. If you feel that taking time to call the PCP will risk your child's health, get help immediately at the nearest emergency room.
You may have to pay if you go to the emergency room for a condition that is not life threatening.
Urgent care
When your child has a medical problem that is not an emergency but requires quick medical attention, this is known as urgent care. Urgent care includes:
- Earaches
- Cuts and scrapes
- Colds, flu, sore throat, coughing or sneezing
- A severe diaper rash
- Low-grade fevers
- Repeated vomiting or diarrhea
- Sprains
You must first call your child's PCP at the number shown on the front of the ID card. When you call your child's PCP, you will be told if you need to take your child to the emergency room. Many illnesses do not need to be treated in the emergency room. Expect appointments for urgent care to be scheduled within 24 hours of your request.
Care when you are away from home
Seton Health Plan covers urgent and emergency care when your child has a sudden illness or injury anywhere in the United States. Health care services received outside the United States are not covered.
If your child is sick or injured and not in serious danger when you are outside the Seton Health Plan service area, call your child's PCP or the 24 hour Nurse Help Line for CHIP 1-888-497-8989 and for STAR 1-855-782-4214.
Seton Health Plan's service area for CHIP & STAR includes:
Bastrop, Burnet, Caldwell, Hays, Fayette, Travis, and Williamson counties.
If your child has an emergency and you are outside the Seton Health Plan service area, go to the nearest emergency room. Call your child's PCP as soon as possible. Your child's PCP will set up follow-up care received outside the Seton Health Plan service area. If you get follow-up care without a referral, Seton Health Plan may not pay for the care. There is no coverage for routine care given outside the Seton Health Plan service area.
Routine care includes:
- Checkups
- Physicals
- Tests
- Non-urgent surgeries
Hospital services
Your child's PCP or a specialist may decide that your child needs care at a hospital. The doctor will arrange for care at a hospital that is in the Seton Health Plan network. Your child is covered for both inpatient and outpatient care. Your child's PCP will need to approve these services.
Filing claims for emergency care
If you receive emergency care from a hospital or doctor not listed in the Seton Health Plan STAR Provider directory, you may need to file a claim. Keep a copy of the bill. Call Member Services for instructions on how to file a claim.