Accessibility Standards

Provider accessibility represents an important element of healthcare quality. Please strive for compliance with these accessibility standards so that our members may have access to needed healthcare services in a timely manner. We recognize that you may not be able to accommodate these time frames when unpredictable circumstances and emergencies occur.

Primary Care Provider Accessibility Standards

All care should be given as expeditiously as condition warrants.

Type of Service	Description	Performance Goal
Emergency Care	Examples: Major trauma injury, chest pain, severe abdominal pain, new onset shortness of breath.	Directed to the nearest emergency room or call 911.
Urgent Care	Examples: Minor trauma injury, unrelieved fever, signs/symptoms of urinary tract infection, children with ear pain and fever.	Appointment is available within 24-48 hours of initial request. As appropriate, members may be directed by the provider or the Company's 24/7 NurseLine to seek care at an Urgent Care Center for onset of symptom(s) or health problems requiring prompt but not immediate medical attention.
Preventative, Regular and Routine Care	Examples: Well child visits, routine physical, visit for recurring/chronic problem(s) and follow-up of non-acute symptoms.	Appointment is available within 30 business days.
Office Wait Times	Office wait time	Wait time should be less than 30 minutes from the time of the scheduled appointment.
After Hours Care	Accessibility to healthcare provider outside of normal business hours.	24-hour, 7 day-a-week (after business hours) on-call coverage system is in place where patients can speak with a healthcare provider. There is accessibility to a healthcare provider outside of normal business hours. Covering provider is expected to be a participating network provider. Respondent or after-hour answering machine must include: Urgent/Emergent instructions as first point of instruction. Information on contacting a covering provider. Telephone number for after-hours provider access. After-hours phone response for Urgent problems should be addressed within 60 minutes.
Patient No-show	Patient no-show	No-shows for scheduled appointments need to be documented in the patient medical record.

All Other Specialists Accessibility Standards

All care should be given as expeditiously as condition warrants.

Type of Service	Description	Performance Goal
Emergency Care	Emergency Care	Directed to the nearest emergency room or call 911.
Urgent Care	Urgent Care	Appointment available within 24-48 hours of initial request. As appropriate, members may be directed by the provider or the Company’s 24/7 Nurse Line to seek care at an Urgent Care Center for onset of symptom(s) or health problems requiring prompt but not immediate medical attention.
Regular and Routine Care	Regular and routine care	Appointment is available within 30 business days for follow-up of non-acute symptoms.
Office Wait Times	Office wait time	Wait time should be less than 30 minutes from the time of the scheduled appointment.
After Hours Care	Accessibility to healthcare provider outside of normal business hours.	24-hour, 7 day-a-week (after business hours) on-call coverage system is in place where patients can speak with a healthcare provider. There is accessibility to a healthcare provider outside of normal business hours. Covering provider is expected to be a participating network provider. Respondent or after-hour answering machine must include: Urgent/Emergent instructions as first point of instruction. Information on contacting a covering provider. Telephone number for after-hours provider access. After-hours phone response for Urgent problems should be addressed within 60 minutes.
Patient No-show	Patient no-show	No-shows for scheduled appointments need to be documented in the patient medical record.

High Volume Specialty Care OB/GYN Accessibility Standards

All care should be given as expeditiously as condition warrants.

Type of Service	Description	Performance Goal
Emergent/Immediate	Emergent/immediate	Directed to the nearest emergency room or call 911.
Urgent Care	Urgent/Non-Emergent	Urgent Care: Appointment is available within 24-48 hours of initial request. As appropriate, members may be directed by the provider or the Company’s 24/7 NurseLine to seek care at an Urgent Care Center for onset of symptom(s) or health problems requiring prompt but not immediate medical attention. Urgent Obstetrical Care: Appointment is available within 24 hours of initial request. Patient may be directed to a facility Obstetrical Department or Emergency Department if an urgent appointment is not available within 24 hours or as requested by the physician.
Routine Care	Routine care	Routine GYN Care: Appointment is available within 60 business days of initial request. Routine Obstetrical Care: Appointment is available within 30 business days of initial request.
Newly Pregnant Care	Newly Pregnant Care	Appointment is available within 10 business days or generally in the second month of pregnancy around 8 weeks after last menstrual period.
Office Wait Time	Office wait time	Wait time should be less than 30 minutes from the time of the scheduled appointment.
After Hours Care	Accessibility to healthcare provider outside of normal business hours.	24-hour, 7 day-a-week (after business hours) on-call coverage system is in place where patients can speak with a healthcare provider. There is accessibility to a healthcare provider outside of normal business hours. Covering provider is expected to be a participating network provider. Respondent or after-hour answering machine must include: Urgent/Emergent instructions as first point of instruction. Information on contacting a covering provider. Telephone number for after-hours provider access. After-hours phone response for Urgent problems should be addressed within 60 minutes.
Patient No-show	Patient no-show	No-shows for scheduled appointments need to be documented in the patient medical record.

High Impact Specialty Care Oncology Accessibility Standards

All care should be given as expeditiously as condition warrants.

Type of Service	Description	Performance Goal
Emergency Care	Emergency care	Directed to the nearest emergency room or call 911.
Urgent Care	Urgent Care	Appointment is available within 24-48 hours of initial request. As appropriate, members may be directed by the provider or the Company’s 24/7 Nurse Line to seek care at an Urgent Care Center for onset of symptom(s) or health problems requiring prompt but not immediate medical attention.
Regular and Routine Care	Regular and routine care	Appointment available within 30 business days for follow-up of non-acute symptoms.
Office Wait Time	Office wait time	Wait time should be less than 30 minutes from the time of the scheduled appointment.
After Hours Care	Accessibility to healthcare provider outside of normal business hours.	24-hours, 7 day-a-week (after business hours) on-call coverage system is in place where patients can speak with a healthcare provider. There is accessibility to a healthcare provider outside of normal business hours. Covering provider is expected to be a participating network provider. Respondent or after-hour answering machine must include: Urgent/Emergent instructions as first point of instruction Information on contacting a covering provider Telephone number for after-hours provider access After-hours phone response for Urgent problems should be addressed within 60 minutes
Patient No-show	Patient no-show	No-shows for scheduled appointments need to be documented in the patient medical record.

Behavioral Health Accessibility Standards (Prescribing and Non-Prescribing)

All care should be given as expeditiously as condition warrants.

Type of Service	Description	Performance Goal
Emergency Care	Emergency care	Directed to the nearest emergency room or call 911.
Care for Non-Life-Threatening Emergencies	Services provided for the onset of symptoms of behavioral health problems that require prompt attention but are not considered emergency care. Example: Suicidal/homicidal ideation without a definitive plan.	Members are scheduled to be seen within 6 hours of contacting the provider. As appropriate, members may be directed by the provider or the Company's 24/7 NurseLine to seek care at an Emergency Department.
Urgent Care Services	Services provided for the onset of symptoms of behavioral health problems that require prompt attention but are not considered emergency care. Example: Symptoms severely affecting daily functioning in such a way that eventual detriment to the member or others will occur.	Members are scheduled to be seen within 48 hours of contacting the provider. As appropriate, members may be directed by the provider or the Company's 24/7 NurseLine to seek care at an Urgent Care Center.
Initial Visit for Routine Care	Initial visit for routine care	Members are scheduled to be seen within 10 business days of request. Excludes follow-up care for an existing problem.
Follow-up Routine Care	Includes visits at later, specified dates to evaluate patient progress and other changes that have taken place since a previous visit.	Within 30 days or as agreed upon by the member and the practitioner.
Office Wait Time	Office wait time	Wait time should be less than 30 minutes from the time of the scheduled appointment.
After Hours Care	Accessibility to healthcare provider outside of normal business hours	24-hour, 7 day-a-week (after business hours) on-call coverage system is in place where patients can speak with a healthcare provider. There is accessibility to a healthcare provider outside of normal business hours. Covering provider is expected to be a participating network provider. Respondent or after-hour answering machine must include: Urgent/Emergent instructions as first point of instruction. Instructions may include: Contact numbers for National and/or Local Suicide Hotline, Mobile Crisis Units Information on contacting a covering provider. Telephone number for after-hours provider access. After-hours phone response for Urgent problems should be addressed within 60 minutes
Patient No-Show	Patient no-show	No-shows for scheduled appointments need to be documented in the patient medical record.

*All covered persons should have access to their provider or covering network provider when the office is closed. After hours phone calls should be returned within 30 minutes.

Coverage and eligibility depend upon the terms and conditions of the applicable benefit plan. These recommendations are not intended to serve as an exclusive course of treatment. Decisions regarding care are subject to individual consideration and should be made by the patient in concert with treating medical personnel.