Sometimes it may be difficult to know when to seek emergency care services or urgent care 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.
In an emergency, go immediately to the nearest emergency care facility to seek care. If you need assistance finding an emergency care facility, call the Tricare Overseas Program Regional Call Center toll free at 0800-589-1599 or civ. 0044-20-8762-8384, Option 1.
Prior authorization is not required. However, continued care must be coordinated to ensure proper medical oversight to include authorizations, benefit coverage and cashless/claimless services.
Urgent care is a medically necessary service required for an illness or injury that is not an emergency, but does require professional attention within 24 hours. A person could require urgent care for a condition 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.
Urgent care requires an appropriate referral and prior authorization. Coordinate all urgent care with your assigned primary care manager when available, or the TOP Regional Call Center to avoid point-of-service charges or claim denials.
If you are traveling away from your TOP Prime Remote location, and urgent treatment cannot wait until your return, contact your assigned primary care manager for a referral or call the TOP Regional Call Center to ensure proper medical oversight, including prior authorizations, benefit coverage and cashless/claimless services.
Become familiar with emergency care facilities
In an emergency, determining where to go or worrying about costs should be far from your mind.
Before a medical emergency occurs, identify the Tricare-authorized emergency care facility closest to you. If you seek care outside of a military treatment facility, you should familiarize yourself with Tricare-authorized freestanding emergency rooms, which are separate structures from hospitals and provide walk-in emergency care to the public.
If you visit a facility that is not Tricare-authorized, you will be responsible for the full cost of care.
If you receive care in a Tricare–authorized emergency facility that is a non-network nonparticipating provider, you may be charged up to 15 percent above the Tricare-allowable charge for services, and you are responsible for paying this amount in addition to any applicable cost-shares.
Note that overseas there may be no limit to the amount that nonparticipating non-network providers may bill, and beneficiaries are responsible for paying any amount that exceeds the Tricare-allowable charge.
For a list of authorized emergency care facilities or to learn more about emergency care, visit www.tricare.mil.