Emergency Care
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.
You do not need to call your PCM or Humana Military before receiving emergency medical care. However, in all emergency situations, you must notify your PCM within 24 hours of or on the business day following admission to coordinate ongoing care and to ensure you receive proper authorization.
Nonemergency Care for Active Duty Service Members
If you are an active duty service member (ADSM) traveling or between duty stations, you must receive all nonemergency care at an MTF if one is available. If an MTF is not available, prior authorization and a referral from your PCM is required before receiving non-emergency civilian care. Make sure you or the requesting provider calls Humana Military for assistance with referral coordination.
Urgent Care
Urgent care services are medically necessary services required 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 could require urgent care for conditions such as a sprain, sore throat, or rising temperature, as each of these has 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 do not coordinate urgent care with your PCM or Humana Military, the care will be covered under the point-of-service (POS) option,* resulting in higher out-of-pocket costs. For cost details, visit
TRICARE's web site. If you are away from home and urgent treatment cannot wait until you return home to see your PCM, you must contact your PCM for a referral or call Humana Military for assistance before receiving care.
Routine(Primary) Care
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 from another provider without a referral from your PCM, you will be using the POS option,* resulting in higher out-of-pocket costs. For cost details, visit
TRICARE's web site.
Services That Do Not Require Referrals
Some services may be obtained without a PCM referral. These include clinical preventive services and the first eight outpatient behavioral health care visits to a network provider per fiscal year (FY) (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 using the POS option,* resulting in higher out-of-pocket costs. For cost details, visit
TRICARE's web site.
For more information about these services, see the
Covered Services, Limitations, and Exclusions section. Remember, you will never need a referral for emergency care.
Note: ADSMs always require a referral for any civilian care, including clinical preventive services, behavioral health care, or specialty care.
* The POS option does not apply to ADSMs, children for the first 60 days following their birth or adoption, emergency care, or beneficiaries with other health insurance.
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