Provider appointment availability
We are committed to providing our members the necessary information to:
- Be able to use their health plan benefits
- Have reasonable access to health services
- Be assured the number of physicians, other health care professionals and facilities will be appropriate to satisfy their health care needs.
Please review this information carefully. If your office currently is not meeting these standards, please take the steps necessary to comply with them to ensure that our members, your patients, have access to quality care. This information and these standards take into account the immediacy of patient needs and common waiting times for comparable services in the community. You should have a system in place in order to evaluate the urgent and emergent needs of members and to determine the appropriate site for care in a timely fashion.
Appointment availability standards
Physicians and other health care professionals will provide or arrange for the provision of covered services to members on a 24 hour a day, seven days a week basis. The following are minimum standards for availability for all lines of business:
Primary care providers
- Emergent care will be assessed, treated or referred immediately.
- Urgent, acute care appointments will be scheduled within 24 hours.
- Preventive care examinations will be scheduled within 42 calendar days.
- Non-urgent appointments for symptomatic conditions will be scheduled within seven calendar days.
- Non-urgent, routine appointments for asymptomatic conditions will be scheduled within 30 calendar days.
- Office wait time for a scheduled appointment will be no more than 30 minutes.
Specialty referral providers
- Urgent, symptomatic condition appointments will be scheduled within 24 hours.
- Non-urgent, specialty referral appointments will be scheduled within 30 calendar days.
Behavioral health providers
- Non-life threatening emergency will be treated within six hours or directed to the nearest emergency room.
- Urgent care appointments will be scheduled within 48 hours.
- Routine office visits will be scheduled within 10 business days.
For commercial lines of business
An emergency is defined as the sudden or acute onset of a symptom or symptoms, including severe pain, that would lead a prudent layperson acting reasonably to believe that a health condition exists that requires immediate medical attention and that failure to provide medical attention would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person's health in serious jeopardy.
Emergent services to screen and stabilize a member are covered if a prudent layperson acting reasonably would have believed that an emergency medical condition existed.
Urgently needed services
Urgent acute care, while not considered life threatening, cannot comfortably be delayed. Practitioners must have a system in place to evaluate the needs of members calling or presenting at the office that enables them to identify conditions requiring urgent and emergent care.
For Medicare Advantage Plans
The provider or the designated covering physician or other health care professional must be available to provide care personally or direct members to the most appropriate treatment setting. If triage is conducted by a health care professional that is not a physician, the minimum credentials of this health care professional must be one of the following:
- Registered nurse
- Nurse practitioner
- Physician assistant
- Certified nurse midwife
- Licensed practical nurse
We define emergency services for members enrolled in our Medicare Advantage plans as covered inpatient and outpatient services that are:
- Furnished by a physician or other health care professional qualified to provide emergency services, and
- Needed to evaluate or stabilize an emergency medical condition.
Emergency medical condition
An emergency medical condition is defined as: A condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, one with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:
- Serious jeopardy to the health of the individual or in the case of a pregnant woman, the health of her unborn child
- Serious impairment to bodily functions or
- Serious dysfunction of any bodily organ or part
Urgently needed services
We define urgently needed services for Medicare Advantage plan members as covered services that are provided when an enrollee is temporarily absent from the Plan's service area (or, under unusual and extraordinary circumstances, provided when the enrollee is in the service area but the Plan's provider network is temporarily unavailable or inaccessible) when such services are medically necessary and immediately required:
- As a result of an unforeseen illness, injury or condition and
- It was unreasonable, given the circumstances, to obtain the services through the Plan
After-hours answering systems
In order for all our members to be able to access their primary care or call share physician after regular office hours, physicians and other health care professionals must have an adequate telephone answering system or service available. If a telephone answering system is utilized after regular office hours, the following guidelines apply:
- The message must be checked frequently to ensure that it is clear, easily understood and contains accurate information such as telephone numbers.
- The answering message must include the name and telephone number of the on-call physician or other health care professional (you or the callshare physician) and complete instructions on how to contact the on-call physician or other health care professional.
Messages that only instruct a member to call 9-1-1 or go to a hospital emergency room do not meet the full requirement for 24 hours a day, seven days a week coverage.
If your office utilizes an answering service, please provide the answering service with the name of the on-call physician or other health care professional, and how the member can contact that provider.
Legislative requirements at both state and federal levels emphasize the importance of demonstrating cultural competency in the provision of health services. This includes members who may:
- Be homeless
- Have physical or mental disabilities
- Have a diverse cultural or ethnic background
- Are limited in English proficiency or reading skills
We seek providers who speak other languages in addition to English and who have an awareness of the social and cultural composition of the community. Additionally, we require that Medicare Advantage members have access to information in their primary language, and that primary care physician offices have provisions for non-English speaking Medicare Advantage patients.
More information, including free guides and online courses, are available on the following Web sites:
Non-English speaking and hearing impaired members
- To ensure accurate interpretation and translation, we strongly encourage utilization of an interpreter service or staff person who is trained in translating medical terminology.
- Asking family members or friends to act as an interpreter is not appropriate. They may not be familiar with medical terms and translation errors may occur, or information may be overlooked or withheld.
Members with visual impairments
The following information may assist you in providing services to visually impaired patients:
- Assign a person in your office to assist visually impaired patients. Identify what to do if a patient needs assistance from their vehicle to your office, with form completion, or to and from the restroom or exam room.
- Braille signs should be posted on restrooms and elevators to meet American Disability Act (ADA) requirements.
- Guide dogs must be permitted to accompany visually impaired patients to all areas of your facility where patients are allowed. An individual with a guide dog may not be segregated from other patients.
Members with physical disabilities
Medical services are accessible to people with physical disabilities. Participating physicians and other health care professionals must ensure the following provisions for access:
- Wheelchair accessible offices
- Clearly-identified handicapped parking spaces
Help in identifying handicapped parking spaces can be obtained from the following sources:
- Signs: Your state's Disabilities Commission can assist you with obtaining signs designating handicapped (including van-accessible) parking. Signs can also be obtained through other commercial vendors.
- Striping and stenciling: Parking space painting and stenciling can be arranged through a variety of commercial vendors. See your telephone directory listing under "Pavement Marking" for the name of a contractor near you.
If your office is unable to serve a particular disabled population or individual, please contact our Provider Contact Center so that other arrangements or referrals can be provided.
Access for Medicare Advantage members with special needs
If your Medicare Advantage patient has a serious, complex medical condition and requires additional assistance navigating the health care system, use the care management referral request form to request case management through our Care Management Intake team. Case management staff will work with your office and the patient to provide assistance with this process, and refer you to the appropriate case manager.