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Provider Handbook
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Urgent Care
Vision Care |
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Urgent Care
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Urgent care services are medically necessary services that are required for illness or injury which would not result in further disability or death if not treated immediately. However, this type of illness/injury does require professional attention and has the potential to develop into such a threat if treatment is delayed longer than 24 hours. An urgent care condition could be a sprain, sore throat, or rising temperature. Beneficiaries enrolled in TRICARE Prime, TPR, and TPRADFM should receive urgent care from their assigned PCM unless they have a referral.
For more information about urgent care, access Chapter 2, Section 7.1 of the TRICARE Policy Manual.
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Vision Care |
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Routine and comprehensive eye examinations as covered by TRICARE are for an evaluation of the eyes not related to another medical or surgical condition. The following CPT codes apply for routine and comprehensive eye examinations: 92002, 92004, 92012, 92014, 92015, 99172, and 99173.
TRICARE’s vision coverage varies based on beneficiary category and program option.
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Active Duty Service Members |
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TRICARE Prime ADSMs must receive all vision care at an MTF unless specifically referred to a network provider, or non-network provider if a network provider is not available. TRICARE Prime Remote ADSMs may obtain a comprehensive eye examination from a network provider as needed to maintain fitness-for-duty status without an authorization. |
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Active Duty Family Members |
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ADFMs are covered for one eye examination annually, regardless of their program option (TRICARE Prime, TRICARE Standard, etc.). If enrolled in TRICARE Prime, these annual exams will also include preventive services as described in “TRICARE Prime Clinical Preventive Eye Examinations” later in this section. |
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Retired Service Members, Family Members, and Others |
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Retired service members, their families, and others who are enrolled in TRICARE Prime are covered for eye examinations under TRICARE’s clinical preventive services benefit. See the next section, “TRICARE Prime Clinical Preventive Eye Examinations,” for coverage details.
If using TRICARE Standard or TRICARE Extra, there is no vision coverage provided under TRICARE after age 6. Newborns and children using TRICARE Standard or TRICARE Extra are covered from birth to age 6 (see Figure 5.2).
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TRICARE Standard and TRICARE Extra Vision Care Coverage
(newborns/children) |
Fig. 5.2
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| Beneficiary |
Coverage |
Provider |
| Infants |
One eye and vision screening at birth and 6 months |
Primary care physician (i.e., pediatrician, family practitioner, etc.) |
Children
(ages 3-6) |
One comprehensive eye exam every two years |
Optometrist or ophthalmologist |
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