No one wants to sit in an emergency room (ER), but after an accident or during a health crisis, it’s good to know TRICARE Prime covers your ER care.
To help you better understand when a trip to the ER is appropriate, TRICARE uses the “prudent layperson” standard. If you, or a member of your family, is suffering a medical emergency—including severe pain—and you believe that without medical attention your life or health will be placed in serious danger, then the ER is the right place for care.
Emergencies fall into three general categories: medical, maternity and psychiatric.
A medical emergency is the sudden and unexpected onset of a medical condition. The problem can be acute, or it can be a chronic condition that worsens. Examples of acute emergency situations include, but are not limited to, the following:
Maternity emergencies are sudden, unexpected medical complications which put the mother or fetus at risk.
A psychiatric emergency leading to an inpatient admission is when, based on an evaluation by a physician (or other qualified behavioral health professional), a patient is deemed to be at immediate risk of serious harm to themselves or others. Immediate and continuous skilled observation is required at this level of care.
In an emergency, you should go to or be taken to the nearest ER for treatment. If an ER visit results in an inpatient admission, you or someone on your behalf should contact your primary care manager (PCM) or Humana Military within 24 hours to ensure that ongoing care can be coordinated.
If you visit an ER for a nonemergency or urgent health care situation, you will face higher charges through the TRICARE Prime point of service option. In addition to being expensive, nonemergency visits to the ER also contribute to the over-crowding of facilities, take resources away from other hospital-based care and compromise the coordination and continuity of your care. To help keep the cost of health care as low as possible, you must obtain all of your nonemergency care from your PCM, or from other providers you have been referred to by your PCM or Humana Military.
By understanding TRICARE’s emergency care guidelines, you can be sure you’re receiving the best care from the proper providers at the lowest cost to you.
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