Kimbrough Ambulatory Care Center (KACC) 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 (MTF) which became effective December 1, 2016.
Historically, beneficiaries have been able to call and get a referral after the fact. Effective December 1, 2016, this option will no longer be available. Unless it is a true emergency, beneficiaries will require authorization from a 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 (POS) 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 (NAL) or your Primary Care Provider 24 hours a day 7 days a week at 301-677-8800 and you will be directed to appropriate care.
Active duty 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 NAL 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 24 hours a day, seven days a week, and you will be directed to the appropriate care. Failure to do so may result in the POS charges mentioned above. Your primary care manager or the NAL will direct you to the appropriate care.
Please 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 by calling 301 -677- 8800.
Retroactive specialty care (non-emergent or urgent): Effective December 1, 2016, KACC 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 at 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 the Chief of Managed Care at Kimbrough Ambulatory Care Center, 2480 Llewellyn Ave STE 5800, Fort Meade, MD 20755-5129. The department's phone number is 301-677-8841 if you have any questions concerning this matter.