Emergency vs. urgent care: It pays to know the difference for TRICARE enrollees|
Posted 4/21/2010 Updated 4/21/2010
by Tech. Sgt. Dana Bice
355th Medical Group
4/21/2010 - DAVIS-MONTHAN AIR FORCE BASE, Ariz. -- When illness or injury strikes, Airmen can save time and money by knowing what TRICARE considers emergency, urgent and routine care.
Treating a moderate steady fever as an urgent need or a sprain as an emergency can equal longer waits and more out-of-pocket costs. Active-duty servicemembers and their families should know the differences between these three types of care:
Anything that could reasonably threaten life, limb or eyesight without immediate treatment is considered an emergency by TRICARE. This includes maternity and psychiatric emergencies believed to be serious medical conditions. Examples of emergency situations are:
· Severe bleeding
· Chest pains
· Inability to breathe
· Spinal cord or back injury
· Severe eye injuries
· Broken bones
In an emergency, anyone on base should call 9-1-1 or immediately go to their nearest emergency room. Within 24 hours after receiving treatment (or the next duty day), TRICARE patients are encouraged to call their primary care manager. This also applies if the visit resulted in an inpatient admission.
If follow-up specialty care is needed as a result of an emergency room visit, please contact your PCM for a referral and prior authorization. If you are assigned to a PCM on base, please call the 355th Medical Group at (520) 228-2778. If you have an off-base PCM, please contact their office directly.
An illness or injury that won't cause further disability or death if not treated immediately, but needs medical attention to keep it from evolving into a greater threat, requires urgent care. Examples of urgent care include:
· Minor lacerations
· Urinary tract infections
· Migraine headaches
· Rising fever
Airmen and their families with on-base PCMs should only use off-base urgent care services if appointments are not available and they receive prior authorization from the base clinic. Even after normal hours, families with on-base PCMs are required to call the 355th MDG and talk to the nurse triage service to determine what care is needed and whether a visit to an urgent-care facility is authorized.
If families with on-base PCMs are not sure whether the situation is urgent or an emergency, please call the 355th MDG any time for clarification.
If families are not assigned on base, they need to contact their off-base PCM for clarifications. Also, members can call TriWest Healthcare Alliance at 1-888-TRIWEST with any questions. Families that don't receive prior authorization for an urgent care visit may be billed for TRICARE Prime's point of service option, which includes additional cost shares and a deductible.
TRICARE defines routine care by what it's not. If it's not an emergency and it doesn't qualify as urgent care, then it's routine.
Also known as primary care, routine care can include well-baby/child care, preventive care appointments, general office visits for treatment of symptoms, follow-up care with the doctor or ongoing care for chronic illnesses and conditions. Routine care is provided by medical professionals at the 355th MDG.
If an Airman or family member visits an urgent care facility without authorization from the medical group, they may pay more out-of-pocket costs.