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TRICARE Prime Handbook
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Getting Care
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Urgent Care
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Urgent care is for an illness or injury that would not result in further disability or death if not treated immediately, but does require professional attention within 24 hours. You would require urgent care for conditions such as a sprain, sore throat, or rising temperature that have the potential to develop into an emergency if treatment is delayed longer than 24 hours.
In most cases, you can receive urgent care from your PCM by making a “same-day” appointment. If you are away from home, contact Humana Military for assistance in obtaining urgent care. If you do not coordinate urgent care with your PCM or regional contractor, the care will be covered under the point of service (POS) option, resulting in higher out-of-pocket costs. See the TRICARE: Summary of Beneficiary Costs flyer to learn about POS fees. |
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Routine (Primary) Care
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Routine (primary) care includes general office visits for the treatment of symptoms, chronic or acute illnesses and diseases, and follow-up care for an ongoing medical condition. Routine care also includes preventive care measures to help keep you healthy. You will receive most of your routine or primary care from your PCM.
You do not need a referral to visit your PCM. If your PCM is unable to provide the care needed, he or she will refer you to another provider. If you receive any routine care without a referral from your PCM, you will be utilizing the POS option, resulting in higher out-of-pocket costs. See theTRICARE: Summary of Beneficiary Costs flyer to learn about POS fees. |
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Services That Do Not Require Referrals
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Some services may be obtained without a PCM referral. These include clinical preventive services and the first eight outpatient behavioral health care visits per fiscal year (October 1- September 30). When seeking clinical preventive services or behavioral health care, you must use a network provider. If you seek care from a non-network provider without a referral from your PCM, you will be utilizing the POS option, resulting in higher out-of-pocket costs. See the TRICARE: Summary of Beneficiary Costs flyer to learn about POS fees.
For more information about these services, see the Covered Benefits, Limitations, and Exclusions section. Remember, you will never need a referral for emergency care. Note: Active duty service members require a referral for any clinical preventive services, behavioral health care, or specialty care.
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Specialty Care
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There are times when you will need to see a specialist for a diagnosis or treatment that your PCM cannot provide. Your PCM will provide referrals to access services from specialty providers and will coordinate the referral request with Humana Military, when necessary. If you receive specialty care without a referral from your PCM, you will be utilizing the POS option, resulting in higher out-of-pocket costs. See the TRICARE: Summary of Beneficiary Costs flyer to learn about POS fees. |
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Referrals for Specialty Care |
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Browse the Web site or call the 1-800-444-5445 to learn about region-specific referral requirements and for details about obtaining referrals.
If you live near an MTF and are referred for specialty care, inpatient admissions, or procedures requiring prior authorization, Humana Military will attempt to coordinate your care at the MTF first. When the services are not available at the MTF, the care will be coordinated with a TRICARE network provider. |
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Specialty to Specialty Referrals |
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If your PCM refers you to a specialist who would like to refer you to another specialist, the specialist will need to contact your PCM. Your PCM or the specialist will contact Humana Military to obtain authorization for additional specialty care, when necessary. |
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Specialty Care Far From Home-Travel Reimbursement |
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Non-active duty TRICARE Prime enrollees who are referred by their PCM for specialty care at a location more than 100 miles (one way) from the PCM’s office may be eligible to have “reasonable travel expenses” reimbursed by TRICARE. Reasonable travel expenses are the actual costs incurred while traveling, including meals, gas/oil, tolls, parking, and tickets for public transportation (i.e., airplane, train, bus, etc.). You must submit receipts for expenses above $75.
TRICARE will use government rates to estimate the reasonable cost. You are expected to use the least costly mode of transportation. TRICARE will reimburse the actual costs of lodging (including taxes and tips) and the actual cost of meals (including taxes and tips, but excluding alcoholic beverages) up to the government rate for the area concerned.
In some cases, a non-medical attendant may also be authorized for travel reimbursement. The non-medical attendant must be a parent, guardian, or another adult family member 21 years of age or older.
To qualify, you must have a valid referral and travel orders from a TRICARE representative at your MTF (if enrolled to an MTF PCM) or from the TRICARE Regional Office (TRO) (if enrolled to a civilian PCM). You should obtain the travel orders before traveling. Contact your local MTF or TRO travel representative if you think you may qualify for this travel reimbursement. |
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TRO Contact Information for Travel Reimbursement Figure 2.1 |
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TRO-North |
Visit www.tricare.mil/tronorth
or call 1-866-307-9749
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TRO-South |
Call 1-800-544-2397 or
1-210-292-3256
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TRO-West
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Call 1-619-236-5324
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You may also visit the TRICARE Web site at www.tricare.mil/primetravel for more information.
Note: Travel for active duty service members is reimbursed through other travel regulations. Active duty service members should contact their unit representatives for information about traveling long distances for medical care.
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