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Provider Accessibility Standards
Provider accessibility represents an important element of healthcare quality. So that our members may have access to needed healthcare services in a timely manner, please strive for complete compliance with these accessibility standards. We recognize that when unpredictable circumstances and emergencies occur, you may not be able to accommodate these time frames.
Medical / Surgical Accessibility Standards and Related Definitions
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Type of Service
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Definition
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Performance Goal
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Emergency
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Sudden, life-threatening symptom(s) or condition requiring immediate medical treatment.
Example: Major injuries; chest pain; severe abdominal pain; new onset shortness of breath.
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Immediate appointment or patient is directed to nearest emergency room.
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Urgent
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Onset of symptom(s) or health problem requiring prompt, but not immediate, medical attention.
Example: Minor injuries; unrelieved fever; signs/symptoms of urinary tract infection; children with ear pain and fever.
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Appointment available within 24 hours.
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Routine
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Non-acute symptoms or follow-up care
Example: Non-urgent, non-emergency assessments or visits; follow-up/post-hospitalization visits; visits for recurring/chronic problems.
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Appointment available within 3 weeks.
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Preventive Care
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Routine, regularly scheduled health assessment.
Example: Well-child visits; routine physical or gynecological exam.
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Appointment available within 8 weeks.
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After Hours Care
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Accessibility outside of normal business hours.
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24-hours-a-day/7-days-a-week on-call coverage.
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Office Wait Time
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Duration of time (when patient arrives on-time for appointment) between patient arrival and beginning of physician encounter.
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Average wait time should not exceed 30 minutes for scheduled appointment.
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Behavioral Health Accessibility Standards and Related Definitions
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Type of Care Needed
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Definition of Service
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Member Should Be Seen
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Life-Threatening
Emergency
Services
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Refers to a sudden or unexpected behavioral health condition that is life-threatening and requires immediate psychiatric treatment to prevent death or disability.
Example: Suicidal/homicidal ideation with a definitive plan.
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If contact is made with the office of the provider, members are scheduled to be seen immediately or will be directed to the closest appropriate provider for emergency treatment.
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Non-Life
Threatening
Emergency
Services
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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.
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Members are scheduled to be seen within 6 hours of contacting the provider.
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Urgent
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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 ADL in such a way that eventual detriment to the member or others will occur.
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Members are scheduled to be seen within 48 hours of contacting the provider.
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Routine
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Services rendered during general office visits that are scheduled for any behavioral health concern which is of a non-emergency or non-urgent nature.
Example: Reactions to environmental life stressors that have affected the member's ability to perform ADL's or the ability to adapt to day to day situations.
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Members are scheduled to be seen
within 10 days of contacting the provider.
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Office Wait Time
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Wait time for a member when (s)he arrives for an appointment on time.
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Wait time for scheduled appointments normally does not exceed 15 minutes.
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After Hours*
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Accessibility outside of normal business hours.
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A 24-hour, 7-day a week on-call system must be in a place for member emergencies after hours.
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Follow-up After
Hospitalization for
Mental Illness
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Outpatient follow-up care after discharge from a mental health hospitalization.
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After discharge from a hospital stay, members are scheduled for the first follow-up visit within 7 days of discharge, and a second follow-up visit within 30 days of discharge.
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