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TRICARE defines an emergency as a medical, maternity or psychiatric condition that would lead a “prudent layperson” (someone with an average knowledge of health and medicine) to believe a serious medical condition exists and the absence of medical attention would result in a threat to the patient’s life, limb or eyesight. This includes a patient requiring immediate medical treatment, or experiencing painful symptoms requiring immediate attention to relieve suffering.
Prudent layperson logic places the decision for seeking emergency care in the hands of patients and the perception that they are in need of immediate care. This can be problematic for facilities that must respond to patients entering the emergency department for treatment. In order to ensure the decision for care is appropriate, providers are advised to submit complete claims.
When submitting claims to TRICARE for emergency services, the facility and the professional provider should make every attempt to include the presenting symptoms as the primary diagnosis. Facility claims filed on UB-04s need to have the primary presenting symptom as the “admit” diagnosis. If the professional emergency service claim is submitted separately on a CMS-1500, we ask that providers also include the primary presenting symptom on their claim.
Many times, a presenting diagnosis provides the explanation needed to apply the prudent layperson logic for the patient’s episode of care; however, the final professional diagnosis or determination may not.
Following these helpful claim filing hints should assist your office or facility in the processing of emergency care claims for TRICARE beneficiaries and prevent possible claim denials.
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