Tricare began an Urgent Care pilot program on May 23, 2016, that extends through May 23, 2019. It allows Tricare Prime, Tricare Prime Remote or Tricare Young Adult-Prime members in the United States to visit Urgent Care facilities twice a year without a referral from a primary care manager (PCM).
Previously, these beneficiaries were required to have a referral from a PCM within 24 hours of going to an Urgent Care facility.
The pilot program allows Tricare beneficiaries to make 2 visits to Urgent Care within each fiscal year, which is October 1 through September 30.
You can now seek help from any Tricare authorized provider. An authorized provider is one that is licensed by a state, accredited by a national organization or meets other standards and is certified to provide benefits under Tricare. These providers are categorized as either network or non-network providers.
If you do receive a referral from your PCM, it does not count against the 2 Urgent Care visits that do not require a referral. If the nurse advice line tells you to go to Urgent Care, it also does not count against your 2 visits per fiscal year.
Tricare is trying out a new policy that allows certain Tricare beneficiaries to utilize Urgent Care facilities without a referral from a PCM.
What is Urgent Care?
If you need medical attention within 24 hours and cannot be seen by your PCM in that time, you need Urgent Care. Some examples of why you might need Urgent Care include: treatment for high fevers, sprains such as your wrist, illness that hinders proper breathing (croup), potential concussion from a fall or other urgent matters that do not threaten life, limb or eyesight.
If an injury does threaten life, limb or eyesight, that is considered an emergency. In that case, you would go to an emergency room.
If you are unsure if your illness requires emergency care, urgent care or simply a scheduled appointment with your PCM, you can call the Tricare nurse advice line at 1-800-Tricare. It is available 24 hours a day, 7 days a week.
What type of Urgent Care providers can you see?
You can see both network and non-network Urgent Care providers. Simply make an appointment or walk in to their facility. There are many different types of Urgent Care providers, all of which are approved for you to visit. These include:
- Family practice
- Internal medicine
- General practice
- Pediatrician
- Obstetrician/Gynecologist
- Urgent Care Clinic/Convenient Care Center
- Physician Assistant
- Nurse Practitioner
- Certified Nurse Midwife
While you are authorized to visit these Urgent Care facilities, you may still have to pay network copayments. Visit the Tricare copayments site to determine if this applies to you. Although you do not need a referral to go to these Urgent Care locations, you still need to inform your PCM about the care you received. You may also need to schedule a follow-up appointment.
Who is eligible for this pilot program?
All active duty service members in Tricare Prime Remote, activated Guard/Reserve members in Prime Remote and all other beneficiaries enrolled in Tricare Prime, Tricare Prime Remote or Tricare Young Adult Prime can take advantage of this pilot program.
If however, the active duty service member, Guard or Reserve member is enrolled in Tricare Prime, they are not eligible. All beneficiaries enrolled in the U.S. Family Health Plan as well as those families enrolled overseas are not eligible. Those traveling in the United States who are enrolled overseas still do not need a referral from their PCM, they simply are not limited to 2 visits to an Urgent Care facility. Any care received overseas does not count as well.
If eligible beneficiaries exceed more than 2 Urgent Care visits within a fiscal year, they will be required to get a referral from their PCM or will be charged a point-of-service fee. You can avoid this fee by calling the nurse line before going to an Urgent Care facility.
Little confused…family members enrolled in Tricare prime stationed overseas can not take advantage of this program? If so, that isn’t fair. Appts are hard to come by just like stateside. Please clear this up for me.
I don’t recall having to get a referral before to use an Urgent Care place. This is like a store quietly raising prices, and then advertising a lower price as a sale.
I visited an urgent care in 2013…claim was paid with no problems. I went again in a Saturday in October 2015 – claim was denied as point of service. Tricare said I needed a referral… I asked when did this change and they said has always been this way. Luckily, my PCP entered a referral three months later and the claim was finally paid. Rather puzzling why the 2013 visit was paid without a referral. Humana Military was the manages care support contractor for both.
No. You always had to have a referral for urgent care places or end up paying for it yourself instead of just a copay.
How about the vets with TriCare For Life who also need the urgent care at times. Sounds like what John Doubledee said, quietly raising the prices and then advertising a lower price as a sale.
If you have Tricare for Life then you must have Medicare too. In that case, under Medicare you can see whoever you want. You don’t need any referrals from Tricare. Tricare for Life picks up the $$ that Medicare doesn’t. That’s what TFL is. It’s a supplemental insurance. When searching for a doctor under Medicare make sure to see if he/she accepts assignment. If they do then it won’t cost you. If they don’t accept assignment then it may cost you extra dollars.
i don’t understand…I have Tricare prime…if I am out of state and have an emergency,i cant be covered going to er? or even in my area not covered by closest er? or ems trip to hosp?
When I read “Tricare Allows 2 Urgent Care Visits Without a Referral”, I said “Thank you sweet Jesus”…then I read “It allows Tricare Prime, Tricare Prime Remote or Tricare Young Adult-Prime members in the United States to visit Urgent Care facilities twice a year without a referral from a primary care manager (PCM).”…So much for that…
I am a retired Air Force with 26 years active duty, I live in Texas, closes bases to me are Naval Air Station Corpus Christi, and 3 bases in San Antonio TX. I initially had Tricare Prime but was discontinued because I don’t live in a Prime Service Area. (As of October 1, 2013, TRICARE Prime will no longer be
available to beneficiaries living in certain areas in the United States). As my son and daughter both live in San Antonio, I traveled to Randolph AFB and talked to the Tricare representative. I asked if I could list my children’s address and still be eligible for Tricare Prime. The representative told me “Mr. Lopez, our hospital is not staffed to take care of our own personnel and their dependents, we send them off base to be seen. Therefore all retirees are seen off base”. My question is, if the retirees who live within the service area are not seen at the base hospital, what difference does it make if I’m seen by a doctor who is willing to accept the fees authorized by Tricare Prime outside the service area. Another issue I have, here in Texas numerous Illegals and Refugees are seen at the Military Hospitals however, we as service members cannot be seen…
We used to be able to go to other Urgent Caress anyway, before United Health changed the rules.