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Outpatient Services
Figure 3.1 provides coverage details for covered outpatient services. Note: This chart is not intended to be all-inclusive. Figure 3.1 Outpatient Services: Coverage Details
| Service |
Description |
| Ambulance Services |
The following ambulance services are covered:
- Emergency transfers between a beneficiary’s home, accident scene, or other location and a hospital
Transfers between hospitals
- Ambulance transfers from a hospital-based emergency room to a hospital more capable of providing the required care
- Transfers between a hospital or skilled nursing facility and another hospital-based or freestanding outpatient therapeutic or diagnostic department/facility
The following are excluded:
- Use of an ambulance service instead of taxi service when the patient’s condition would have permitted use of regular private transportation
- Transport or transfer of a patient primarily for the purpose of having the patient nearer to home, family, friends, or personal physician
- Medicabs or ambicabs that function primarily as public passenger conveyances transporting patients to and from their medical appointments
Note: Air or boat ambulance is only covered when the pickup point is inaccessible by a land vehicle, or when great distance or other obstacles are involved in transporting the beneficiary to the nearest hospital with appropriate facilities, and the patient’s medical condition warrants speedy admission or is such that transfer by other means is not advisable.
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| Ancillary Services |
Covers certain diagnostic radiology and ultrasounds, diagnostic nuclear medicine, pathology and laboratory services, and cardiovascular studies |
| Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) |
Generally covered if prescribed by a physician and if directly related to a medical condition. Covered DMEPOS generally includes:
- DMEPOS that are medically necessary and appropriate and prescribed by a physician for a beneficiary’s specific use
- Duplicate DMEPOS items that are necessary to provide a fail-safe, in-home life-support system
(In this case, “duplicate” means an item that meets the definition of DMEPOS and serves the same purpose but may not be an exact duplicate of the original DMEPOS item. For example, a portable oxygen concentrator may be covered as a backup for a stationary oxygen generator.)
Note: Prosthetic devices must be approved by the U.S. Food and Drug Administration. |
| Emergency Services |
TRICARE defines an emergency as a medical, maternity, or psychiatric condition that would lead a “prudent layperson” (someone with average knowledge of health and medicine) to believe that a serious medical condition exists; that the absence of immediate medical attention would result in a threat to life, limb, or sight; when a person has severe, painful symptoms requiring immediate attention to relieve suffering; or when a person is at immediate risk to self or others. |
| Home Health Care |
Covers part-time or intermittent skilled nursing services and home health care services
(All care must be provided by a participating home health care agency and have prior authorization from Humana Military.)
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| Individual Provider Services |
Covers office visits; outpatient, office-based medical and surgical care; consultation, diagnosis, and treatment by a specialist; allergy tests and treatment; osteopathic manipulation; rehabilitation services (e.g., physical and occupational therapy and speech pathology services); and medical supplies used within the office |
| Laboratory and X-ray Services |
Generally covered if prescribed by a physician
(Some exceptions apply, e.g., chemosensitivity assays and bone density X-ray studies for routine osteoporosis screening.)
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