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, such as after hours.

• Beneficiaries assigned to a PCM at a military treatment facility (MTF) must contact their PCMs or TriWest at 1-888-TRIWEST (1-888-874-9378) before receiving urgent care treatment. This is to obtain the MTF-specific guidelines for obtaining urgent care.
• Beneficiaries with civilian PCMs are required to obtain prior authorization for urgent care. TriWest is available to help locate a nearby MTF urgent care clinic or a network provider for urgent care needs. Please contact 1-888-TRIWEST (1-888-874-9378) for assistance.
• Any follow-up care for an urgent care or emergency care visit should be directed to the beneficiaries’ PCMs.

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.