Urgent care vs. emergency care:understanding the difference Published Dec. 16, 2008 By Kim Kinser Humana Military Healthcare Services KEESLER AIR FORCE BASE, MISS. -- During the holiday season, sickness or injury can occur unexpectedly. Health care facilities, along with other businesses, may have special hours of operations. Being armed with the right information and an understanding of the difference between "emergency care" and "urgent care" can ease your mind and be helpful during an often stressful time of the year. Urgent care services are medically necessary, non-life threatening conditions requiring professional attention within 24 hours. Examples of urgent conditions are sprains, sore throats, rising fever, coughs and colds, sinus infections and earaches. Illnesses aren't confined to regular weekday office hours. If you and your family are enrolled in Tricare Prime or Tricare Prime Remote and find yourself in need of medical attention after hours, contact your primary care manager before you seek urgent care. Most network or medical treatment facility providers have an on-call process available after hours to assist in urgent situations. If you're unable to contact your PCM or on-call provider for direction, notify your PCM within 24 hours or the next business day following care to get a referral. Prime enrollees have a $12 co-pay when seeking urgent care from a Tricare-network urgent care facility. Emergency care services are defined as medical, maternity, or psychiatric emergencies, believed to be serious medical conditions, requiring immediate medical attention. Examples of medical emergencies include, but aren't limited to, severe bleeding, chest pain, shortness or inability to breathe, spinal cord or back injury and severe eye injuries. In an emergency, go or be taken to the nearest emergency room for care. Tricare defines an emergency room as an organized hospital-based facility for patients who present immediate medical attention that's available 24/7. Prime beneficiaries seeking emergency services in a network facility ER have a $30 co-pay. Prime beneficiaries visiting an ER for services that are determined to be nonemergency or urgent health care based on the ER claim may face higher charges through the Tricare Prime point of service. Prime beneficiaries shouldn't seek emergency care for clear cases of routine illnesses. To assist in keeping the cost of health care as low as possible, obtain all of your nonemergency care from your PCM or from other providers you've been referred to by your PCM or Tricare. Tricare Standard beneficiaries have the freedom to choose a Tricare-authorized provider when seeking urgent or emergency care, but if the beneficiary chooses to use the Extra benefit by seeing a network provider, their out-of-pocket cost is less. If an Extra or Standard beneficiary seeks treatment in an ER and the claim reflects routine care, the facility charge may be denied and the professional services shall be allowed. If Humana Military Healthcare Services refers an Extra or Standard beneficiary to an ER, the care is allowed. Before an emergency or illness arises, familiarize yourself with Tricare network or authorized facilities in your area. To locate a Tricare network facility or provider in the south region, log on to the HMHS Web site, http://www. humana-military.com/south/bene/tools-resources/BeneSiteProvLoc.asp. Look under the Tricare network facility section and click on the appropriate link. If you don't have access to the Internet or prefer to speak with someone for help in locating a network provider, call beneficiary services, 1-800-444-5445. Beneficiaries should keep their PCM informed of any urgent or emergency services they receive so referrals can be written and follow-up care arranged.