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Providing Urgent and Emergency Care to Out- of-Area TRICARE Beneficiaries (Article 5) |
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With the holiday season upon us, many TRICARE beneficiaries will be traveling out of their home TRICARE region to visit friends and relatives, and some will require emergency or urgent care. There are a number of things to consider when treating an out-of-area beneficiary.
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Is a referral required? |
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For emergency care services, neither TRICARE Prime nor TRICARE Standard beneficiaries need a referral or authorization. However, if admitted to the hospital, a TRICARE Prime beneficiary should contact his or her primary care manager (PCM) or
regional contractor within 24 hours to coordinate ongoing care. TRICARE Standard beneficiaries are also encouraged to contact their family doctors if they are admitted to a hospital.
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For urgent care services, TRICARE Prime beneficiaries must obtain a referral from their military treatment facility, PCM or regional contractor. If a referral is not acquired, the claim will be paid under the point of service (POS) option, and the beneficiary will incur higher out-of-pocket costs. If the beneficiary has other health insurance that provides primary coverage, the
POS option does not apply. TRICARE Standard beneficiaries do not need a referral for urgent care.
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Where should the claim be submitted? |
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When you provide services to a TRICARE Prime beneficiary from a different region, submit all reports and claims information to the region in which the beneficiary is enrolled. If the patient is not enrolled in TRICARE Prime, submit all reports and claims
information to the region where the patient resides, not the region where he or she is receiving care. The beneficiary is responsible for applicable cost-shares.
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If you have a question or concern about a claim for an out-of-area beneficiary, call the appropriate number listed below for assistance.
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North Region 1-877-TRICARE (1-877-874-2273)
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Connecticut, Delaware, the District of Columbia, Illinois, Indiana, Kentucky, Maine, Maryland, Massachusetts, Michigan, New Hampshire, New Jersey, New York, North Carolina, Ohio, Pennsylvania, Rhode Island, Vermont, Virginia, West Virginia,
Wisconsin and portions of Iowa (Rock Island Arsenal area), Missouri (St. Louis area) and Tennessee (Ft. Campbell area)
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South Region 1-800-403-3950 |
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Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, Oklahoma, South Carolina, Tennessee (excluding the Ft. Campbell area) and Texas (excluding the El Paso area)
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West Region 1-888-TRIWEST (1-888-874-9378) |
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Alaska, Arizona, California, Colorado, Hawaii, Idaho, Iowa (excluding the Rock Island Arsenal area), Kansas, Minnesota, Missouri (excluding the St. Louis area), Montana, Nebraska, Nevada, New Mexico, North Dakota, Oregon, South Dakota, Texas (the southwestern corner only, including El Paso), Utah, Washington, and Wyoming
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For more information on treating out-of-area TRICARE patients, see Sections 7 and 8 of the TRICARE Provider Handbook. |
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Created: November 15, 2007
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