Appointment Availability Standards During Office Hours and After Office Hours Access Standards

STANDARDSDEFINITIONSCHEDULED APPOINTMENT TIME FRAME
Emergency Care
(Emergent)1
Emergency care is medical care given for a condition that, without immediate treatment, could result in placing the member's life or general health in severe jeopardy, or cause severe impairment in one or more bodily function(s), or cause severe dysfunction of one ormore body organ(s) or part(s). Examples of emergency conditions include seizure, stab/gunshot wounds, diabetic coma, cardiac arrest, meningitis, obvious fracture (bone showing through skin). Requires immediate face-to-face medical attention. If a practitioner or covering practitioner is not immediately available, the member or representative should call 911.
Urgent Care Urgent care is medical care given for a condition that, without timely treatment, could be expected to deteriorate into an emergency, or cause prolonged, temporary impairment in one or more bodily function(s), or development of a chronic illness or need for a more complex treatment. Examples of urgent conditions include abdominal pain of unknown cause, unremitting new symptoms of dizziness cause unknown, suspected fracture. Requires timely faceñto-face medical attention within 24 hours of member notification of the existence of an urgent condition.
Non-Urgent Sick Medical care given for an acute onset of symptoms that is not emergent or urgent in nature. Examples of non-urgent sick visit include cold symptoms, sore throat and nasal congestion. Requires face-to-facemedical attention within 48 to 72 hours of member notification of a nonurgent condition, as clinically indicated.
Routine Primary Care Routine primary care services include the diagnosis and treatment of conditions to prevent deterioration to a more severe level, or minimize/reduce risk of development of chronic illness or the need for more complex treatment. Examples include psoriasis, chronic low back pain. Requires a face-to-face visit within 4 weeks of member request.
Preventive Care/ Routine Physical Exam Preventive care or services are rendered to avert disease/illness and/or its consequences. There are three levels of preventive care: primary, such as immunizations, aimed at preventing disease; secondary, such as disease screening programs, aimed at early detection of disease; and tertiary, such as physical therapy, aimed at restoring function after the disease has occurred. Requires a face-to-face visit within 4 weeks of member request.
Routine Specialty Care Specialty care ismedical care given by a specialist. Examples include podiatry and neurology. Requires a face-to-face visit within 4 weeks of member request.
Assessment Regarding Ability To Perform/ Return To Work An appointment for assessment of the member's mental health/medical status needs as related to recommendation regarding member's capability to perform or return to work. Requires appointment within 2 business days of member request.
Initial Family Planning/ Reproductive Health Visits Family planning/reproductive health services include screening and treatment services to prevent, diagnose, alleviate or ameliorate sexually transmitted diseases, anemia, cervical cancer, glycosuria, proteinuria, hypertension and breast disease. Also includes routine gynecological examinations, pregnancy testing andHIVcounseling and testing. Requires a face-to-face visitwithin 2weeks/14 days of member request.
Initial Prenatal Visit Initial prenatal visit is medical care given for a condition in which the patient has tested positive for pregnancy and is requesting an initial visit. Requires appointment scheduled within 3 weeks for first trimester, 2 weeks for second trimester and 1 week for third trimester. A schedule of follow-up appointments is given to the patient based on American College of Obstetricians and Gynecologists Guidelines and practitioner risk assessment.
Routine GYN Visit Routine GYN care is a situation in which a short delay in treatment would not result in deterioration to amore severe level or cause need formore complex treatment. Examples include routine pap smear, refill of oral contraceptives. Requires a face-to-face visit within 4 weeks of member request.
Pediatrician Conference A prenatal visit (during 3rd trimester) is recommended forparentswho are at high risk, for first-time parents and for those who request a conference. Requires appointment scheduled within 10 days of member request or as clinically indicated.
Follow-up Visit For Breast Fed Infants Follow-up visit for a breast-fed infant is medical care given for a condition in which delay of treatment could result in failure to thrive, dehydration and/or malnutrition. Requires face-to-face medical attention within 48 to 72 hours of discharge.
Initial Newborn PCP Visit An appointment for assessment of a newborn's physical status to ascertain the general well-being of the child and to promote early detection of immediate medical needs and promote early educational opportunities. Requires appointment within 2 weeks of hospital discharge.
Routine Well-Child Visits Well-child services are those provided tomembers under 21 years of age that are essential to: a) prevent, diagnose, prevent the worsening of, alleviate or ameliorate the effects of an illness, injury, disability, disorder or condition; b) assess the overall physical, cognitive and mental growth and developmental needs of the child; and c) assist the child to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the individual and those functional capacities that are appropriate for individuals of the same age. Requires well-child services within 4 weeks of member request.
Any Other Condition   Up to medical judgment of the practitioner.

1Emergency Care (Emergent): An emergencymedical conditionmeans amedical or behavioral condition, the onset of which is sudden, thatmanifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in: (1) placing the health of the person afflicted with such condition in serious jeopardy; or (2) serious impairment to such person's bodily functions; or (3) serious dysfunction of any bodily organ or part of such person; or (4) serious disfigurement of such person.

Behavioral Health Standards

STANDARDS DEFINITION SCHEDULED APPOINTMENT TIME FRAME
Emergency Care
(Emergent)
An emergency appointment for life threatening mental health or substance abuse conditions (suicidal intent) or for non life threatening mental health or substance abuse conditions that neverthe- less necessitate immediate intervention, i.e., psychosis. Requires immediate face-to-face medical care. The member or representative should call 911.
Urgent Care An urgent appointment for an acute mental health or substance abuse condition, or a condition that may become an emergency if not treated, i.e., acute major depression and acute panic disorder. Requires appointment scheduled within 24 hours.
Follow-Up for Emergency/Hospital Discharge An appointment for a follow-up visit related to an emergency room or hospital discharge for evaluation of acute mental health condition. Requires appointment scheduled within 5 days of member request or as clinically indicated, but no later than 7 days post discharge.
Routine Care An appointment for specific mental health or substance abuse concerns that are not of an urgent nature, i.e., marital problems, tensions at work and general anxiety disorder. Requires appointment within 10 business days of member request.
STANDARDS DEFINITION AND BENCHMARK
Average Speed To Answer The amount of time it takes for a "live voice" to answer the telephone in the Mental Health Department. Telephone call answered by a live voice within 30 seconds.
Call Abandonment The number of calls that went unanswered by a "live voice" and ultimately voluntarily disconnected in the Mental Health Department. Less than 5 percent.

Additional Standards

STANDARDS DEFINITION AND BENCHMARK
Geographic (GEO) Access Standards For All Physicians
  • Members must be offered a choice of at least three (3) PCPs, three (3) OB/GYNs and three (3) high-volume specialists within program distance/travel time standard.
  • Normal condition/primary road - 30 miles/30 minutes.
  • Rural areas - 60 miles/60 minutes.
Office Waiting Time Standard Members with appointments are seen within 30 minutes of their scheduled appointment time or arrival time, whichever is later. If a delay is unavoidable, the member should be informed and alternatives offered to the patient.
24 Hour Accessibility All network practitioners must be available, either directly or through coverage arrangements, 24 hours a day, 7 days a week, 365 days a year. Availability must be by live voice direct to the practitioner or covering practitioner, or via an answering service that can reach the practitioner or covering practitioner. If an answering machine is used, it must provide an option to directly contact the practitioner or covering practitioner, or a beeper number, in case of emergencies. An answering machine cannot simply refer the member to an emergency room, unless it is a life-threatening issue.