Prior approval required for urgent or out-of-area care
By TriWest Healthcare Alliance
/ Published March 22, 2007
HOLLOMAN AIR FORCE BASE, N.M. --
TRICARE Prime beneficiaries enrolled at military treatment facilities are now required to obtain prior approval from their prime care manager before seeking urgent or out-of-area care treatment. This Department of Defense policy applies to active-duty family members, retirees and family members of retirees.
Authorization is not required for emergencies. Beneficiaries may continue to seek emergency care at the nearest emergency room. There is a significant difference between emergency and urgent care. An emergency is a condition that is emergent or life-threatening.
Urgent care is defined as medically necessary services required for an illness or injury that would not result in further disability or death if not treated immediately, but requires professional attention and has the potential to develop such a threat if treatment is delayed longer than 24 hours. An urgent care condition could be a sprain, sore throat or rising temperature.
If a beneficiary does not receive prior approval from the PCM for non- emergency care, the care may be covered under the point-of-service option, which includes a deductible, higher co-payments and cost-shares. A beneficiary may appeal the payment of a claim under the POS option if they believe the care was an emergency.
After receiving instructions from their PCM, beneficiaries may call 1-888-TRIWEST to locate a network provider nearby.
To contact a PCM at anytime, call 505-572-2778.