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tricare and ER visits

saturdaynightdoubletreesaturdaynightdoubletree member
in Military Families
We just started using Tricare in the last month. DD has been sick and cranky, but the pedi is closed today. I was thinking of taking her to the ER just to get checked out. Is there a fee/copay to go to the ER with Tricare? TIA
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Re: tricare and ER visits

  • leslie13510leslie13510
    With Prime, yes it should be free.  With Standard you'll have a co-pay.
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  • gosse1kmgosse1km
    Even with Prime, you need to call Tricare ahead of time ot get it okayed or they might not cover it.
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  • runnergirl2008runnergirl2008 member

    imagegosse1km:
    Even with Prime, you need to call Tricare ahead of time ot get it okayed or they might not cover it.

    This. I had to go to an ER early in my pregnancy and while there they gave me an ultrasound. Because I didn't have the ultrasound approved previously I had to pay for it. They can be very particular. Even if you decide to take her to an urgent care place make sure you call first.  

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  • iluvmytxrgriluvmytxrgr member
    I've had to go to the ER several times through pregnancies and with my kids.  I've never had to call Tricare ahead of time when I went and never had to pay extra for not calling. 
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  • NSLNSL member
    Unless it's a medical emergency you need pre-authorization (under Prime) to go to a non-military provider such as an ER or urgent care.  We've had to do it several times while traveling and it's a bit of a PITA.
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  • krista613krista613
    you should be fine with either if you go to the military hospital in your area.
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  • Green*FlamingoGreen*Flamingo member
    You can call the Nurse Advice Line for your MTF to see if the issue warrants a trip to the ER.
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  • joecherishsmejoecherishsme
    We are all Prime and I had to take my 12 mo. son to the ER last weekend, at night because he cut his head open and I thought he might need stiches. He ended just needing glue to close it but I was not going to drive 30 min. to the military hopsital only to wait in the ER for hours with my baby. It quailifed as an emergency in my book that's why I went and Tricare hasn't billed me for anything yet and if they do I'll fight it.
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  • Lissa832Lissa832 member

    imageiluvmytxrgr:
    I've had to go to the ER several times through pregnancies and with my kids.  I've never had to call Tricare ahead of time when I went and never had to pay extra for not calling. 

    This.

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  • amandafikriamandafikri
    Was in the ER several times during my pregnacy, started with standard, and switched to prime. Ive never payed a co pay for either
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  • fmoore723fmoore723

    It honestly depends on your area. When we were stationed in Virginia---they did not approve going to Urgent Care Centers--it had to be an emergency room. If you went to the ER---you didnt need an approval. Ive never paid a bill---and know that several times I took the kiddos into a smaller ER (more like an urgent care) for strep throat/ear infections---and never got a bill.

    Now, here, in Arizona--you can go to Urgent Cares but must call for approval ahead of time. Essentially if the MTF is closed or booked up for the day, they will approve you. If you dont have time to call or think its an emergency, you can go to the ER and they dont penalize you.

    I think its always in your best interest to give them a heads up though.

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  • blondnearbyblondnearby

    From my personal experiences (there have many over the past 5 years), is it depends on who your PCM is associated with.

    Let me explain further,  If you live with in 100 miles (may be 120) I am assuming you are not prime and have a PCM assigned to you through there. This would require you to attend the ER at the MTF.  If you are not at a close distance to the MTF, or it's closed you must call tricare first for prior authorization  (this is negated if Tricare deems your ER visit a medical emergency, but be careful because just because you think it is, does not mean they will).

    If you are prime, you are assigned an outside PCM.  If your PCM is part of a medical group, you are authorized to go to their UC center as well as their ER without calling in advance.

    I, personally, have dealt with both situations.  Triwest tried to bill me for a ER visit which ultimately lead to three months inpatient for DD#1 because I went to an ER not on base.  It wasn't until a year later, and the fact that DD#1 ultimately would have been transported to said hospital anyway, that the bills were reimbursed.  

    With DD#2, her PCM (prime) told us to head to the local children's hospital instead of the one her group was associated with.  Triwest tried to bill me again for the ER visit as well as the week inpatient until I had a signed statement from my DD's PCM that stated she told us to go to that particular hospital.  

    As far as Tricare assigning emergency status to an ailment, the situation involving DD#2 involved a very large overdose of Reglan due to a doctor's error.  With in minutes of arriving, three attending physician's were at my DD#2's side trying to save her life.  Yeah, Triwest didn't think it was an emergency and thus billed me because I didn't call first.

    These are just my personal experiences and I would hate for someone else to have to deal with Tricare the way I did and still have to. 

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