Appointment access standards for PCPs, specialty care and behavioral health practitioners

As a participating provider, please be reminded of your contractual obligation to help ensure our members have prompt access to services. The provider manual is located on our provider website (www.empireblue.com/nymedicaiddoc) and contains our guidelines on access of care for PCPs, specialty care practitioners and behavioral health practitioner. We use several methods to monitor adherence to these standards. Monitoring is accomplished by:

• Assessing the availability of appointments via phone calls by our staff or designated vendor to the provider’s office.
• Analysis of member complaint data.
• Analysis of member satisfaction surveys.

 

The following information is excerpted from the provider manual for your review:

 

Physician/provider access goals and calendar requirements

One of our goals is to make accessing medical care easy for members by assuring a comprehensive network of physicians and providers close to their homes. As a result, we have implemented the following plan-wide geographic access goals as guidelines for our network. It is our goal to provide members with access to the following within our defined service areas:

• Two PCPs within five miles of each member
• Two OB/GYNs within eight miles of each member
• Full range of specialists (including non-MD allied providers) within 15 miles of each member

 

Calendar access requirements

 

PCPs

• Preventive care — For members scheduling periodic routine exams (well-care/preventive visits), appointments should be available within 45 calendar days of a member’s call. Examples of care provided to prevent illness or injury include routine physical examinations, immunizations, mammograms and Pap smears.
• Urgent care appointment with acute symptoms — Appointments should be available within 24 hours of the member’s call. Examples of care provided for a nonemergent illness or injury with acute symptoms that require immediate care include sprains, flu symptoms, minor cuts and wounds, sudden onset of stomach pain and severe, nonresolving headache.
• Routine care with symptoms — Members must have access to care within five days of their call.
• Routine check-up — Members must have access to care within 10 business days of their call. This consists of care provided for nonsymptomatic visits or follow-up.

 

• Though it is important for members to have the continuity of receiving care from their PCPs, there are occasions when you may not be available at a time that meets their scheduling needs. As a reminder, we now contract with walk-in centers and urgent care facilities, which are listed in our directory.

 

Specialists

• Urgent care appointment with acute symptoms — Appointments should be available within 24 hours of the member’s call. Examples of care provided for a nonemergent illness or injury with acute symptoms that require immediate care include sprains, flu symptoms, minor cuts and wounds, sudden onset of stomach pain and severe, nonresolving headache.
• Routine check-up — Members must have access to care within 15 calendar days of their call. Care provided for nonsymptomatic visits for health check.

 

Behavioral health providers

• Non-life threatening emergency needs — Members must be seen or have appropriate coverage directing the member within six hours. Emergent behavioral health care provided when a member is in crisis, experiencing acute distress and/or other symptoms, and needs immediate attention, but there is no risk of loss of life.
• Urgent needs — Members must be seen or have appropriate coverage directing the member within 24 hours. This includes nonemergent behavioral health illness that requires immediate care, member experiencing significant psychological distress with symptoms that impairs daily functioning, but there is no risk of loss of life.
• Initial routine office visit — Members must be seen within 10 business days. New patient nonurgent appointment scheduled after intake assessment or a direct referral from a treating practitioner.
• Follow-up routine visit — Members must be seen within five calendar days. Nonurgent behavioral health care includes when a member has been scheduled for a nonurgent consultation post-emergency room visit, post-inpatient care or requires services, including follow-up and existing medication management.

 

After-hours coverage

After-hours coverage, which is required by the Participating Provider Agreement, consists of an attendant or recording assisting the member in accessing urgent services outside of regular office hours. Note that telephone answering machines and voice mail are not acceptable means of providing access for members if the answering machine or voice mail message only refers members to the emergency room or to call 911.

 

The recording or live person must refer the patient to urgent care center, 911 or emergency room, and also provide the option to contact a live health care practitioner (via cell, pager, beeper, transfer system), get a call back for urgent instructions, or be transferred directly to the available practitioner or on-call practitioner.

 

Timely access to physicians is a major priority of our members and employer groups. The requirements adopted reflect not only their expectations, but market norms. We will be assessing physicians against these requirements through our customer satisfaction surveys and provider surveys, as well as follow-up on any members’ complaints received. However, we are sensitive to problems related to seasonal services, the varying nature of practice specialties, and the challenges faced by busy practices. If your office routinely fails to meet these access and after-hours standards, it is important that you document and we understand the reasons that the requirements are not met.

 

NYE-NU-0198-20 February 2020