By Cheryl Jones
Chief, Managed Care
Kimbrough Ambulatory Care Center announces important changes to the local policy and process for obtaining emergency room, urgent care and medical specialty services for prime beneficiaries enrolled with the Medical Treatment Facility.
Historically, beneficiaries have been able to call and get a referral after the fact. Effective Dec. 1, this option will no longer be available. Unless it is a true emergency, beneficiaries will require authorization from an MTF provider before seeking medical care.
Emergency room services: Beneficiaries do not require a referral to obtain emergency services.
Emergency services are those services needed to prevent the loss of life, limb or eyesight. Should any prime beneficiary seek emergency room services for non-emergent issues, they may incur point-of-service charges, which include a $300 deductible and 50 percent cost share.
If you are having a true emergency, dial 911 or go to the closest emergency room.
If you are unsure if your situation is a true emergency, call the Nurse Advice Line or your primary care provider 24 hours a day, seven days a week at 301-677-8800. You will be directed to appropriate care.
Active-duty service members must always contact their primary care manager by calling 301-677-8800 as soon as possible after an emergency room visit so appropriate authorization can be coordinated.
Urgent care: All beneficiaries must contact the clinic or the Nurse Advice Line prior to seeking urgent care services.
If you are experiencing medical symptoms after duty hours that you feel could progress into an emergency situation, call 301-677-8800. Failure to do so may result in the point-of-service charges. Your primary care manager or the Nurse Advice Line will direct you to the appropriate care.
Remember: If you are directed to a specialty care follow-up appointment from an emergency room visit or urgent care facility visit, you must obtain authorization for this specialty care before care is rendered outside the emergency room or urgent care setting. This can be accomplished by contacting your primary care manager team at 301-677-8800.
Retroactive specialty care (non-emergent or urgent): Effective Dec. 1, Kimbrough will no longer authorize retroactive specialty care referral requests. Beneficiaries must have prior authorization before seeking specialty care in the network.
This local change is in compliance with Chapter 1, Section 9.1 of the Tricare Policy Manual 6010.54M, which states: “Failure to obtain a primary care manager referral when one is required will result in the service being paid under point-of-service procedures with a deductible for outpatient services and cost-shares for in and outpatient services.”
Questions regarding covered benefits can be directed to the Tricare beneficiary counseling and assistance coordinator, located in the referral management office, by calling 301-677-8982.
Should you feel that you have extenuating circumstances regarding any denial of payment for emergency room, urgent care or specialty care services, a request for reconsideration should be submitted in writing and forwarded to:
Chief of Managed Care at Kimbrough Ambulatory Care Center, 2480 Llewellyn Ave., Suite 5800, Fort Meade, MD 20755-5129.
For more information, call 301-677-8841.