Skilled Nursing Facility Care

Skilled nursing care typically is not provided in a nursing home or a patient’s home, but rather in an SNF. An SNF is required to be Medicare-certified and must enter into a participation agreement with TRICARE. Under the SNF benefit, TRICARE covers skilled nursing care and rehabilitative (physical, occupational, and speech) therapies, room and board, prescribed drugs, laboratory work, supplies, appliances, and medical equipment.

For TRICARE to cover a patient’s admission to an SNF, the patient must have had a qualifying medical condition that was treated in a hospital for at least three consecutive days (not including day of discharge). Admission to the SNF may be covered as long as the patient is admitted within 30 days of his or her discharge from the hospital (with some exceptions for medical reasons). You will need to demonstrate the patient’s need for skilled nursing services for TRICARE to pay for the SNF care.

For more information about SNF care, access Chapter 2, Section 4.1 of the TRICARE Policy Manual and Chapter 8 of the TRICARE Reimbursement Manual at the TRICARE Manuals web page.
          

Urgent Care

Urgent care services are medically necessary services that are required for illness or injury that 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.