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TRICARE Access to Care Standards

BJACH Leadership

Access to Care standards differ by the level of care sought. TRICARE Prime beneficiaries are entitled to the following access to care standards in accordance with 32 CFR 199.17(p)(5)(ii):

1. Emergency Care: Beneficiaries seeking emergency care should proceed to the nearest emergency room or call 911 (or other local emergency assistance number) for immediate medical attention. In accordance with DoDD 6000.14, reference (a) above, Military Health System (MHS) beneficiaries have the right to access emergency healthcare services when and where the need arises. Emergency services are covered in circumstances where acute symptoms are of sufficient severity that a "prudent layperson" could reasonably expect the absence of medical attention would result in serious health risks or death.

2. Urgent (Acute) Care: Beneficiaries should have an appointment to visit an appropriately trained provider within 24 hours and within 30 minutes travel time of the beneficiary's residence. If this appointment cannot be provided within these access standards either in a military treatment facility (MTF) or the civilian network, the beneficiary must be offered a referral and authorization to seek urgent care outside the civilian network. Urgent care is defined as a non-emergency illness or injury for which you need medically necessary treatment. An urgent care condition will not result in further disability or death if not treated immediately; however, treatment should take place within 24 hours of illness or injury to avoid further complications and unnecessary suffering.

3. Routine Care: Beneficiaries must have an appointment with an appropriately trained provider within seven calendar days and within 30 minutes travel time of the beneficiary's residence.

4. Wellness and Health Promotion Services: Beneficiaries must have an appointment with an appropriately trained provider four weeks and within 30 minutes travel time of the beneficiary's residence.

5. Referrals for Specialty Care Services: Beneficiaries must have an appointment with an appropriately trained provider four weeks and within one hour's travel time of the beneficiary's residence.

Office Waiting Times: 32 CFR 199.17(p)(5)(ii) states that office waiting times in non-emergency circumstances shall not exceed 30 minutes, except when emergency care is being provided to patients and the normal office schedule is disrupted. The Appointments Standardization Commander's Guide to Access Success further defines appointing practices and standard appointment types in relation to the above care categories (reference http://www.tricare.osd.mil/tai/cguide.htm).

(Excerpt from HA POLICY: 06-007, Feb 21, 2006)
 

COL Mark C. Wilhite
CSM David L. Hunt
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