JOINT BASE SAN ANTONIO-RANDOLPH, Texas –
Receiving urgent care at a civilian facility is an easy process, but some TRICARE Prime beneficiaries are not following the rules, costing themselves and the Air Force money.
These beneficiaries are not receiving authorization from their primary care managers, requiring them to pay out of pocket.
"Beneficiaries will call us and ask for retro authorization when they need urgent care, but we don't do retro authorization in the local area," Pat Aguon, 359th Medical Support Squadron beneficiary counseling and assistance coordinator, said.
TRICARE Prime patients who need urgent care - "when an illness or injury is serious enough to seek health care right away, but not so severe as to require emergency room care" - require a referral from their PCM prior to their visit, Aguon said. They may also call 916-9900 to receive authorization.
"It's very easy to call and get authorization," she said.
If they do not have authorization, they may or may not be required to pay at the civilian urgent care facility, Aguon said.
"If they are made to pay, they can file a claim and it will be paid at the point-of-service charge, which is a deductible of $300 and a 50 percent cost share," she said. "However, the civilian provider may file the claim for them and they would be liable for the deductible and cost share."
Examples of illnesses and injuries that require urgent care are earaches, toothaches, joint sprains, muscle pulls and urinary tract infections.
Aguon said beneficiaries who are "in fear of losing their life, eyesight or a limb" require emergency care and should call 911 or go to the nearest civilian or military emergency room. The closest military emergency room to Joint Base San Antonio-Randolph is at San Antonio Military Medical Center.
She said beneficiaries do not need authorization for emergency care, but they must notify their PCM or regional contractor within 24 hours or the next business day after receiving emergency care.
Army Brig. Gen. W. Bryan Gamble, TRICARE Management Activity deputy director, said many people use the emergency room when their medical issue is not an actual emergency.
"This contributes to long ER wait times, high costs and unnecessary medical care," he said. "Sometimes, using an urgent care clinic may be your best choice and can help responsibly preserve the TRICARE benefit for future generations of military families."
For more information, call Aguon at 652-4303.