Understanding the difference between urgent and emergent care can help you and your family avoid unnecessary out-of-pocket costs.
In addition to reviewing the information below, please contact your local military treatment facility (MTF) for specific policy details in your area.
What is Urgent Care?
An urgent condition is an illness or injury that won’t cause further disability or death if not treated immediately, but requires professional attention to prevent it from developing into a greater threat.
Urgent care centers should be used only if your primary care manager is not available, such as after hours. Regardless, you must still obtain an authorization for urgent care; otherwise you will be billed under TRICARE Prime’s point-of-service (POS) option, which includes additional cost-shares and a deductible. Examples of urgent care situations include, but are not limited to, the following:
A beneficiary may appeal the payment of a claim under the POS option if they believe it is in error.
How is Emergency Care Different?
TRICARE defines an emergency as a medical condition that a "prudent layperson" — someone with an average knowledge of health and medicine — believes could threaten life, limb or eyesight without immediate treatment. If you feel the situation requires immediate medical treatment, or there are painful symptoms requiring immediate attention to relieve suffering, the situation is an emergency. Examples of emergency situations include, but are not limited to the following:
In an emergency, you should call 911 or go to (or be taken to) the nearest emergency room for treatment. You or someone on your behalf needs to contact your primary care manager (PCM) or TriWest within 24 hours if the emergency room visit results in an inpatient admission, so ongoing care can be coordinated.
For more information about TRICARE benefits, visit www.triwest.com or call 1-888-TRIWEST (874-9378).