Emergency vs. Urgent Care: It Pays to Know the Difference

What is Urgent Care?

An urgent condition is an illness or injury that won’t cause further disability or death if not treated immediately, but requires professional attention to prevent it from developing into a greater threat.

Urgent care centers should be used only if the primary care manager (PCM) is not available. In other words, if you are enrolled in TRICARE Prime, you need to use your PCM for urgent care whenever possible. You may seek urgent care elsewhere if your PCM is unavailable or unable to provide the services you need on an urgent basis. If you do, however, your claim may be processed with Point of Service charges if it is not preauthorized or does not meet the criteria for urgent care. If you have questions about preauthorization or urgent care criteria, please contact TriWest at 1-888-TRIWEST (874-9378).

Any follow-up care for your urgent care visit should be directed to your PCM.

Examples of urgent care situations include, but are not limited to, the following:

• Minor lacerations
• Urinary tract infections
• Earaches
• Migraine headaches
• Sprains
• Rising fever

You may appeal the payment of a claim under the POS option if you believe it was billed in error.

How is Emergency Care Different?

TRICARE defines an emergency as a medical condition that a “prudent layperson” – someone with an average knowledge of health and medicine – believes could threaten life, limb or eyesight without immediate treatment. If the situation requires immediate medical treatment, or there are painful symptoms requiring immediate attention to relieve suffering, the situation is an emergency. Examples of emergency situations include, but are not limited to, the following:

• Severe bleeding
• Chest pains
• No pulse
• Inability to breathe
• Spinal cord or back injury
• Severe eye injuries
• Broken bones

In an emergency, call 911 or go (or be taken to) the nearest emergency room for treatment. Be sure to contact your primary care manager (PCM) or TriWest within 24 hours if the emergency room visit results in an inpatient admission, so ongoing care can be coordinated.