Definition of Emergency and Urgent Care Situations

Emergency services are defined as being services furnished to an individual who has an emergency medical condition as defined in 42 CFR 424.101. The CMS has adopted the definition of emergency medical condition in that section of the Code of Federal Regulations (CFR). However, it seemed clear that Congress intended that the term “emergency or urgent care services” not be limited to emergency services since they also included “urgent care services.” Urgent Care Services are defined in 42 CFR 405.400 as services furnished within 12 hours in order to avoid the likely onset of an emergency medical condition.

 For example, if a beneficiary has an ear infection with significant pain, CMS would view that as requiring treatment to avoid the adverse consequences of continued pain and perforation of the eardrum. The patient’s condition would not meet the definition of emergency medical condition because immediate care is not needed to avoid placing the health of the individual in serious jeopardy or to avoid serious impairment or dysfunction. However, although it does not meet the definition of emergency care, the beneficiary needs care within a relatively short period of time (which CMS defines as 12 hours) to avoid adverse consequences, and the beneficiary may not be able to find another physician or practitioner to provide treatment within 12 hours.


EMERGENCY CARE

TRICARE defines an emergency as a serious medical condition that the average person would consider to be a threat to life, limb, sight or safety. If you have an emergency, call 911 or go to the nearest emergency room. You do not need prior authorization before getting emergency medical care.

However, in all emergencies, your primary care manager (PCM) or regional contractor must be notified within 24 hours or on the next business day following admission to coordinate ongoing care and to ensure you receive proper authorization. Depending on your TRICARE plan, emergency care services may have applicable cost-shares.

Other Types of Emergencies

Maternity: A maternity emergency is a sudden unexpected medical complication that puts the mother or baby at risk. Psychiatric: A psychiatric emergency is when a person is at immediate risk of serious harm to self or others as a result of a mental disorder and requires immediate, continuous skilled observation at the acute level of care. This assessment is based on a psychiatric evaluation performed by a doctor or other qualified mental health care professional with hospital admission authority.

Dental: Most dental emergencies, such as going to the emergency room for a severe toothache, are not a covered medical benefit under TRICARE. For more information about dental care, visit www.tricare.mil/dental.

Certain instances of dental care are covered as adjunctive dental care under TRICARE’s medical benefit. Adjunctive dental care is dental care that is medically necessary in the  treatment of an otherwise covered medical—not dental— condition. Prior authorization is required.

URGENT CARE

Urgent care services are medically necessary services required for an illness or injury that would not result in further disability or death if not treated immediately, but does require professional attention within 24 hours. You may require urgent care for conditions such as a sprain or rising fever, as each of these has the potential to develop into an emergency if treatment is delayed longer than 24 hours.

Urgent Care Pilot

The Urgent Care Pilot, which began May 23, 2016, lets most TRICARE Prime beneficiaries get two urgent primary care visits in the U.S. each fiscal year (Oct. 1–Sept. 30) without a referral or prior authorization.

The Urgent Care Pilot is available to most TRICARE Prime beneficiaries living or traveling in the U.S. This includes:

• Active duty service members (ADSMs) (including National Guard or Reserve members activated for more than 30 days) in TRICARE Prime Remote (TPR)

• Non-ADSMs in TRICARE Prime, TPR or TYA Prime

• TOP beneficiaries traveling in the U.S. (not limited to two visits)

You don’t qualify for the Urgent Care Pilot if you’re:

• An ADSM (including National Guard or Reserve members activated for more than 30 days) in TRICARE Prime (urgent care is managed by your assigned military hospital or
clinic to ensure readiness)

• In the US Family Health Plan

• Using TRICARE Standard and TRICARE Extra or TFL (urgent care is covered without referral or prior authorization under these programs)

• A TOP beneficiary seeking care outside the U.S.


Emergency Services

Emergency services are not subject to prior authorization requirements and are available to our members 24 hours a day, seven days a week, 365 days a year.

An emergency medical condition is a medical condition manifesting itself by acute symptoms of sufficient severity, which may include severe pain or other acute symptoms, such that a prudent lay person who possesses an average knowledge of health and medicine could reasonably expect that the absence of immediate medical attention could reasonably be expect to result in any of the following:

 Serious jeopardy to the health of the member, including a pregnant woman or fetus
 Serious impairment to bodily functions
 Serious dysfunction of any bodily organ or part
 A pregnant woman having contractions

SHP shall not:

 Require prior authorization for an enrollee to receive pre-hospital transport or treatment or for emergency services and care;

 Deny payment for treatment obtained when a representative of the SHP instructs the enrollee to seek emergency services.

 Specify or imply that emergency services and care are covered by the Plan only if secured within a certain period of time;

 Use terms such as "life threatening" or "bona fide" to qualify the kind of emergency that is covered; or

 Deny payment based on a failure by the enrollee or the hospital to notify SHP before, or within a certain period of time after, emergency services and care were given.

 Deny claims for emergency services and care received at a hospital due to lack of parental consent.


Pre-hospital and hospital-based trauma services and emergency services and care will be  authorized.


SHP shall cover all screenings, evaluations, and examinations that are reasonably calculated to assist the provider in arriving at the determination as to whether the member has an emergency medical condition. If the provider determines that an emergency medical condition does not exist, SHP is not required to cover services rendered subsequent to the provider's determination unless authorized by the Plan.

If the provider determines that an emergency medical condition exists, and the enrollee notifies the hospital or the hospital emergency personnel otherwise have knowledge that the patient is an enrollee of SHP, the hospital must make a reasonable attempt to notify the enrollee's PCP, if known, or SHP, if the Plan has previously requested in writing that it be notified directly of the existence of the emergency medical condition

If the hospital, or any of its affiliated providers, do not know the enrollee's PCP, or have been unable to contact the PCP, the hospital must notify SHP as soon as possible before discharging the enrollee from the emergency care area; or notify the Plan within twenty four (24) hours or on the next business day after the enrollee’s inpatient admission.

If the hospital is unable to notify SHP, the hospital must document its attempts to notify the Plan, or the circumstances that precluded the hospital's attempts to notify the Plan. SHP shall not deny coverage for emergency services and care based on a hospital's failure to comply with the notification requirements of this section.

SHP shall cover any medically necessary duration of stay in a non-contracted facility, which results from a medical emergency, until the Plan can safely transport the member to a participating facility. SHP may transfer the member, in accordance with state and federal law, to a participating hospital that has the capability to treat the member’s emergency medical condition. The attending emergency physician, or the provider actually treating the member, is responsible for determining when the member is sufficiently stabilized for transfer, and that determination is binding.

Emergencies at Out-of-State Hospitals
Emergency services provided in out-of-state hospitals are reimbursable when an emergency arises from an accident or illness, the health of the recipient would be endangered if the care or services were postponed until he returned to Florida or if the health of the recipient would be endangered if he undertook travel to return to Florida. 


Is a prior authorization required in an emergency situation? 

No.  If you are taken to an emergency room in an emergency situation, you do not need a prior authorization.  Note: An emergency is an instance in which the absence of medical attention could jeopardize a person's life, health, or ability to regain maximum function, or could subject a person to severe pain.

Is a prior authorization needed if I go to an out-of-network or out-of-Florida doctor or hospital? 
If your doctor or hospital is NOT a Blue Cross and Blue Shield of Florida participating network provider or is located outside of Florida and the service which you are seeking requires a prior authorization, then it’s your responsibility to ensure the provider obtains a prior authorization for you. It’s easy to initiate: Simply have your non-network or out-of-Florida doctor or hospital call the number on the back of your ID card. If a prior authorization is not obtained, you may be responsible for the entire cost.  

Exception:
 In an emergency situation, a prior authorization is NOT required.  An emergency is an instance in which the absence of medical attention could jeopardize a person's life, health, or ability to regain maximum function, or could subject a person to severe pain.

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