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Urgent and Emergent Care


Emergent 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.

Note: Most dental emergencies, such as going to the emergency room for a severe toothache, are not a covered medical benefit under TRICARE. Active duty service members (ADSMs) receive dental care from military dental treatment facilities and, if necessary, from civilian providers through the TRICARE Active Duty Dental Program. Active duty family members and retirees and their family members may be eligible to enroll in either the TRICARE Dental Program or the TRICARE Retiree Dental Program, depending on their status. For more information, refer to "Dental Options" in the Covered Services, Limitations, and Exclusions section of this handbook.

If a medical emergency occurs, call 911 or go to the nearest emergency room. You do not need to call your PCM or regional contractor before receiving emergency medical care (including overseas care). However, in all emergencies, you must notify your PCM within 24 hours of or on the next business day following admission to coordinate ongoing care and to ensure you receive proper authorization. Additionally, ADSMs enrolled in TPR should contact their service point of contact (SPOC) as soon as possible.

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 regional contractor, the care will be 19 SECTION 3 GETTING CARE 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 contact your regional contractor for assistance before receiving care.

* The POS option does not apply to ADSMs, children for the first 60 days following their birth or adoption, emergency care, beneficiaries with other health insurance, or the first eight behavioral health outpatient visits to a network provider for a medically diagnosed and covered condition per fiscal year (FY) (October 1–September 30).
 
Last Update: December 17, 2013