By Sharon Foster
TRICARE Management Activity
7/13/2011 – FALLS CHURCH, Va. (AFNS) — Even the best-planned vacations can be disrupted with injury or sickness.
While TRICARE follows beneficiaries when they travel, understanding when something constitutes an emergency room or urgent care visit can help the beneficiary save money and time, officials said.
TRICARE defines an emergency as a medical, maternity or psychiatric condition that would lead someone with an 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.
“Some examples of emergency situations may include head injuries, broken bones, chest pains and the inability to breathe,” said Kathleen Larkin, the director of the Health Plan Policy Division of Health Affairs/TRICARE Management Activity. “If you or a family member require emergency care while on vacation, call 911 immediately or go to the nearest ER. If you are admitted, you must notify your primary care manager or regional health care contractor within 24 hours or on the next business day to coordinate ongoing care.”
Authorization is not required for emergency care before receiving treatment.
If a beneficiary is vacationing overseas with family, assistance with locating an emergency facility or emergency number for the country in which he or she is visiting can be obtained by calling the TRICARE Overseas Program contractor. This contact information can be located at www.tricare.mil/contactus.
When seeking care from a host-nation provider, beneficiaries should be prepared to pay up front for services and then file a claim with the appropriate claims processor. Active-duty service members and Prime-enrolled active-duty family members should contact the TOP regional call center in the area prior to seeking care when possible or prior to making payment.
“TRICARE defines urgent care as a medical service needed within 24 hours when an illness or injury would not result in further disability or death if not treated immediately,” Larkin said. “Some examples of urgent-care situations may include earache, toothache, sprain or urinary-tract infection.”
If urgent-care treatment cannot wait until the beneficiary returns home to see a PCM, he or she must contact the PCM for a referral or call the regional health care contractor for
assistance before receiving care.
Failure to obtain a referral may cause care to be covered under the point-of-service option and will incur higher costs. The POS option does not apply to ADSMs, newborn or adopted children in their first 60 days, emergency care or if the beneficiary has other health insurance. Beneficiaries can visit www.tricare.mil/cost for POS details.
ADSMs should seek urgent care at a military treatment facility. If away from home, ADSMs should contact their regional health care contractor for assistance in obtaining urgent care. ADSMs living outside the U.S. who are unable to seek urgent care at an MTF should contact the TOP regional call center.
Beneficiaries may use any TRICARE pharmacy option when vacationing, but should be sure their Defense Enrollment Eligibility Reporting System information is current. At overseas host-nation pharmacies, beneficiaries will pay up front and file for reimbursement of covered charges with the overseas claims processor.
If beneficiaries require emergency dental care, they can contact their dental care program for further assistance. This contact information can be found at www.tricare.mil/contactus.
When vacationing, beneficiaries should always be prepared for injuries or sickness by knowing their TRICARE benefit and how it can best work for them.