Medical Mutual - Health Plans for Life

Provider 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 Providers and Specialists
Accessibility Standards

Type of Service

Description: Examples

Performance Goal

Emergency Care

Emergency care
Example: Major trauma injuries; chest pain; severe abdominal pain; new onset shortness of breath.

Immediate appointment or patient is directed to nearest emergency room or call 911.

Urgent Care

Onset of symptom(s) or health problem requiring prompt, but not immediate, medical attention.
Example: Minor trauma injury; unrelieved fever; signs/symptoms of urinary tract infection and children with ear pain and fever.

Appointment available within 24 hours of initial request. As appropriate, members may be directed by the provider or Company's 24/7 NurseLine to seek care at an Urgent Care Center for onset of symptoms or health problems requiring prompt but not immediate medical attention.

Regular and Routine Care

Follow-up care for non-acute symptoms
Example: Visits for recurring/chronic problem(s).

Appointment available within 30 days for follow-up of non-acute symptoms.

Preventive Care

(Primary Care Providers Only)

Example: Well-child visits, routine physical or gynecological exam.

Appointment available within 30 days.

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-a-day, 7-days-a-week on-call coverage system where patients can speak with a healthcare provider. There is accessiblity to a healthcare provider outside of normal business hours.

  • Covering provider must be a participating network provider
  • 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/Emergent problems should be addressed within 30 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

Type of Service

Description: Examples

Performance Goal

Emergency Care

Emergency care
Example: major trauma injury, severe abdominal pain, vaginal bleeding, leakage of fluid if pregnant.

Patient is directed to the nearest emergency room or call 911.

Urgent Care

Onset of symptoms(s) or health problem requiring prompt, but not immediate, medical attention
Example: minor trauma injury, signs/symptoms of urinary tract infection, vaginal infections

Appointment is available within 24 hours of initial request.

Routine Care

Follow-up care for non-acute symptoms.
Example: gynecological exams, renewal of oral contraceptives

Appointment is available within 2 months.

Office Wait Time

Office wait time

Wait time should be less than30 minutes from the time of the scheduled appointment.

After Hours

Accessibility to healthcare provider outside of normal business hours.

24-hours-a-day, 7-days-a-week on-call coverage system where patients can speak with a healthcare provider. There is accessiblity to a healthcare provider outside of normal business hours.

  • Covering provider must be a participating network provider
  • 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/Emergent problems should be addressed within 30 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

Type of Service

Description: Examples

Performance Goal

Emergency Care

Emergency care
Example: major trauma injury, chest pain, severe abdominal pain, new onset shortness of breath

Immediate appointmentor patient is directed to the nearest emergency room or call 911.

Urgent Care

Onset of symptoms(s) or health problem requiring prompt, but not immediate, medical attention
Example: Minor trauma injury, unrelieved fever, signs/ symptoms of urinary tract infection, children with ear pain and fever

Appointment is available within 24 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

Follow-up care for non-acute symptoms.
Example: Visits for recurring/chronic problem(s)

Appointment is available within 30 days for follow-up of non-acute symptoms.

Office Wait Time

Office wait time

Wait time should be less than30 minutes from the time of the scheduled appointment.

After Hours

Accessibility to healthcare provider outside of normal business hours.

24-hours-a-day, 7-days-a-week on-call coverage system where patients can speak with a healthcare provider. There is accessiblity to a healthcare provider outside of normal business hours.

  • Covering provider must be a participating network provider
  • 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/Emergent problems should be addressed within 30 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)

Type of Service

Description

Performance Goal

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 that excludes follow-up care for an existing problem.

Members should 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.

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