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:
- One day or less for urgent care
- One week for routine care
- 28 days 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 - is 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 - is medical care to promote health maintenance and prevention, for example Pap tests. The maximum waiting time for well care is four weeks.
Specialty Care - is 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.