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To ensure that beneficiaries who use the Department of Defense
(DoD) Military Health System receive medically necessary care
when they need it, DoD leadership developed access standards for
TRICARE Prime enrollees. What's important is ensuring that
access to care is easy, fast and logical.
TRICARE's standards for access are easy:
One day or less for urgent care
One week for routine care
One month for specialty or wellness care
30 minutes or less in the provider's waiting room
30 minutes or less travel time to the primary care provider's
office.
Emergency services are available and accessible within the
TRICARE Prime service area 24 hours a day, seven days a week.
In an emergency, TRICARE beneficiaries should call 911 or go to
the nearest emergency room.
Access standards give TRICARE leaders a tool to measure the
actual waiting and drive times beneficiaries experience and to
fix problems when they occur. By measuring access to care, DoD
leaders can improve customer service. Their goal is to provide
beneficiaries the world's best access to health care. To ensure
they receive evaluation of illness in a timely manner, TRICARE
Prime enrollees have access to primary care manager services 24
hours a day, seven days a week.
Besides making access to care easy to track and improve, DoD
leaders also realize those long waits at the provider's office
squander away valuable time. That's why the standards for access
also measure how fast beneficiaries receive care for
non-emergency situations at the provider's office. TRICARE's
goal of treatment within 30 minutes of patient's arrival at the
provider's office is very ambitious compared with other health
plans.
With the aid of TRICARE's health care finders, even referrals
from primary care managers are handled rapidly. If a beneficiary
needs to see a specialist, the care is arranged swiftly through
TRICARE's vast provider network. In some regions, the services
of a health care finder are available to beneficiaries 24 hours
a day, seven days a week. TRICARE's access standard for travel
time to the specialty care provider's office is 60 minutes.
Even if a health plan is easy, fast and logical to navigate,
though, problems can occur. How leadership deals with problems
is another form of health care access. For example, TRICARE
provides assistance with enrollment, claims and health plan
questions through the various TRICARE service centers in the
regions.
Following is a list of the categories of care with the
corresponding TRICARE access standard. When reading this list,
remember that a health care provider using professional
standards and clinical judgment may specify more appropriate
appointment guidelines, based on the needs of the beneficiary.
Emergency
A sudden or unexpected condition or the acute worsening of a
chronic condition that is threatening to life, limb or sight and
that requires immediate medical treatment to relieve suffering
from painful symptoms.
Under a recent TRICARE policy change, emphasis is placed on the
symptoms that prompted the emergency room visit rather than the
final diagnosis. This is called the Prudent Layperson Standard,
which means that someone with average knowledge of health and
medicine could reasonably expect that the absence of medical
attention would result in placing a person's health in serious
jeopardy, serious impairment to bodily functions or serious
dysfunction of any bodily organ or part.
Urgent Care
Medical attention for a condition that, while not life or limb
threatening, could become more serious if not treated. Examples
of urgent care include eye or ear infections and suspected
bladder infections. When traveling away from home, this type of
care, unlike emergency care, requires the authorization of a
primary care manager.
If a beneficiary is enrolled in TRICARE Prime, urgent care must
be obtained at the primary care manager's office. If a
beneficiary is not sure where to go for treatment, he or she may
contact a health care finder. The services of health care
finders are available 24 hours a day, seven days a week. Urgent
care is provided in one day or less.
Routine Care
Medical care for symptoms-such as colds and flu or low-back
pain, for which intervention is required, but is not urgent. The
maximum waiting time for routine care is one week.
Well Care
Medical care to promote health maintenance and prevention, for
example Pap tests. The maximum waiting time for well care is
four weeks.
Specialty Care
Provided by a specialist in TRICARE's provider network after
referral by a primary care manager. The maximum waiting time for
specialty care is four weeks.
After Hours Care
Patients must be treated by the local emergency room. A full
examination determines further care by emergency personnel or
after hours care personnel.
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