Using Your Benefits Outside the Network or Service Area

Using Your Benefits When You’re Outside the Balance Network
Balance by CCHP is an HMO plan, which means most care is covered when you use in-network doctors, hospitals, and pharmacies in our service area (San Francisco and San Mateo Counties). However, we understand that sometimes you may need care outside the network. Some services may be covered outside the network or service area under specific circumstances, as described below.

Emergency Care (Covered Anywhere)

You are covered for emergency services anywhere in the world.
• Call 911 or go to the nearest emergency room.
• No prior authorization is required.
• After your condition is stabilized, you may be required to transfer to a Balance network facility for continued care to be covered. If you remain at an out‑of‑network facility after stabilization without approval, you may be responsible for the full cost of care.

Urgently Needed Care Outside the Service Area

If you are temporarily outside the service area and need care that cannot safely wait until you return, Balance covers urgently needed services.
Urgently needed care includes:
• Sudden illness or injury
• Severe pain
• Complications of pregnancy

Urgently needed service obtained outside the service area do not require prior authorization.

Non-Emergency Care Outside the Network (Restrictions Apply)

Routine, elective, or follow-up care outside the network is not covered unless:
• Your Primary Care Physician (PCP) or Balance approves the care in advance, or
• No appropriate in-network provider is available and prior authorization is granted.

If out‑of‑network care is approved: You pay the same cost‑sharing as in‑network services.

If out‑of‑network care is not approved: You may be responsible for the full cost of services.

For Individual & Family health plan members, please refer to your plan’s Evidence of Coverage document (EOC) here for further information.

For Employer Group health plan members, please refer to your plan’s Evidence of Coverage document (EOC) here for further information.