When unexpected medical care is needed, especially after hours or on weekends, it can be difficult to know what type of care you need and where to go.
Urgent care facilities have popped up everywhere in the civilian world these past few years, but can you use them, too, with your TRICARE benefits? How does that work? Most non-military patients can just walk-up to urgent care clinics and deal with their insurance companies later, but TRICARE has a different procedure for military members and their families to use.
Armed with information provided by TRICARE, we attempt to clear up any confusion concerning the use of these facilities.
Urgent Care or ER?
Urgent medical care does not threaten life, limb or eyesight, but needs attention to prevent it from becoming a serious risk to health. Your primary care manager (PCM) can be your best resource for deciding where and when to get care, but may not be available after hours or on weekends (when, it seems, most of the incidents requiring urgent care occur).
Steps to Take
• Call your PCM or family doctor.
• If your PCM or family doctor cannot provide care on the day you call, you will be directed to use a local network urgent care provider. If you are unable to reach your PCM or family doctor, a referral may be required. See the urgent care referral requirements below.
• If you cannot locate a network urgent care provider, visit our Network Provider Directory or call TRICARE for assistance. When using the online directory, type in your ZIP code and under Specialty select Urgent Care Center or Convenient Care Clinic.
Understanding Urgent Care
Is urgent care the same as a medical emergency?
No. Urgent care is not the same as a medical emergency. A medical emergency threatens life, limb or eyesight. If you or someone you know is experiencing a medical emergency, call 911 or go to the nearest emergency room.
What are the benefits of an urgent care clinic?
Urgent care clinics are conveniently located and have shorter wait times than emergency rooms.
Urgent Care Referral Requirements
Do I need a referral before I go to an urgent care clinic?
TRICARE Prime, TRICARE Prime Remote and TRICARE Young Adult Prime members need a referral before going to an urgent care clinic. To obtain a referral to an urgent care clinic, call your PCM or Military Treatment Facility (MTF). If you are unable to reach your PCM or MTF, call TRICARE.
TRICARE Standard, TRICARE For Life, Dual Eligible beneficiaries and beneficiaries with Other Health Insurance (OHI) do not require a referral from TRICARE.
What happens if I go to an urgent care clinic without a referral?
When TRICARE Prime, TRICARE Prime Remote and TRICARE Young Adult Prime members use an urgent care clinic without a referral, they are choosing the Point of Service option, which has higher out-of-pocket costs. The Point of Service option does not apply to active duty service members, who may be responsible for the entire cost of their care.
The bottom line is, military members and their families can use urgent care facilities, but if the proper prior approval procedures are not followed, it may result in a higher out-of-pocket cost for those who use them.
