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.

Standards	Definition	Scheduled Appointment Time Frame
Emergency Care	Emergency care is medical care given for a condition that, without immediate treatment, could result in placing the member’s life or general health in severe jeopardy, or cause severe impairment in one or more bodily function(s), or cause severe dysfunction of one or more body organ(s) or parts. Examples of emergency conditions include major trauma injury, chest pain, severe abdominal pain, new onset shortness of breath.	Directed to the nearest emergency room or call 911.
Urgent Care Visit	Urgent care is medical care given for a condition that, without timely treatment, could be expected to deteriorate into an emergency or cause prolonged, temporary impairment in one or more bodily function(s), or development of a chronic illness or need for a more complex treatment. Examples of urgent conditions include 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 Visit	Routine, preventive care or services are rendered to avert disease/illness and/or its consequences, including the diagnosis and treatment of conditions to prevent deterioration to a more severe level. Examples include 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. (ACA Exchange Standards – 15 business days)

Standards

Definition

Scheduled Appointment Time Frame

Emergency Care

Emergency care is medical care given for a condition that, without immediate treatment, could result in placing the member’s life or general health in severe jeopardy, or cause severe impairment in one or more bodily function(s), or cause severe dysfunction of one or more body organ(s) or parts.

Examples of emergency conditions include major trauma injury, chest
pain, severe abdominal pain, new onset shortness of breath.

Directed to the nearest emergency room or call 911.

Urgent Care Visit

Urgent care is medical care given for a condition that, without timely treatment, could be expected to deteriorate into an emergency or cause prolonged, temporary impairment in one or more bodily function(s), or development of a chronic illness or need for a more complex treatment.

Examples of urgent conditions include 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 Visit

Routine, preventive care or services are rendered to avert disease/illness and/or its consequences, including the diagnosis and treatment of conditions to prevent deterioration to a more severe level.

Examples include 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.

(ACA Exchange Standards – 15 business days)

High Volume Specialty Care OB/GYN Accessibility Standards

All care should be given as expeditiously as condition warrants.

Standards	Definition	Scheduled Appointment Time Frame
Emergency Care	Emergency care is medical care given for a condition that, without immediate treatment, could result in placing the member’s life or general health in severe jeopardy, or cause severe impairment in one or more bodily function(s), or cause severe dysfunction of one or more body organ(s) or parts.	Directed to the nearest emergency room or call 911.
Urgent Care Visit	Visits requiring prompt evaluation for new symptoms that cannot wait for a routine appointment but are not emergency conditions.	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.
Routine Care Visit	Obstetric (OB) Routine Care Visits are related to pregnancy, childbirth, and postpartum care. Gynecologic (GYN) Routine Care Visits are related to women's reproductive and sexual health outside of pregnancy. Examples include health screenings like a pap smear, contraceptive counseling, STD testing.	Appointment is available within 30 business days of initial request.
Newly Pregnant Care	Initial prenatal visit is medical care given for a condition in which the patient has tested positive for pregnancy and is requesting an initial visit.	Appointment is available within 10 business days or generally in the second month of pregnancy around 8 weeks after last menstrual period.

High Impact Specialty Care Oncology Accessibility Standards

All care should be given as expeditiously as condition warrants.

Standards	Definition	Scheduled Appointment Time
Emergency Care	Emergency care is medical care given for a condition that, without immediate treatment, could result in placing the member’s life or general health in severe jeopardy, or cause severe impairment in one or more bodily function(s), or cause severe dysfunction of one or more body organ(s) or parts.	Directed to the nearest emergency room or call 911.
Urgent Care Visit	Urgent care is medical care given for a condition that, without timely treatment, could be expected to deteriorate into an emergency or cause prolonged, temporary impairment in one or more bodily function(s), or development of a chronic illness or need for a more complex treatment.	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.
Regular and Routine Care Visit	Routine, preventive care or services are rendered to avert disease/ illness and/or its consequences, including the diagnosis and treatment of conditions to prevent deterioration to a more severe level.	Appointment is available within 30 business days for follow-up of non- acute symptoms.

All Other Specialists Accessibility Standards

All care should be given as expeditiously as condition warrants.

Standards	Definition	Scheduled Appointment Time Frame
Emergency Care	Emergency care is medical care given for a condition that, without immediate treatment, could result in placing the member’s life or general health in severe jeopardy, or cause severe impairment in one or more bodily function(s), or cause severe dysfunction of one or more body organ(s) or parts.	Directed to the nearest emergency room or call 911.
Urgent Care Visit	Urgent care is medical care given for a condition that, without timely treatment, could be expected to deteriorate into an emergency or cause prolonged, temporary impairment in one or more bodily function(s), or development of a chronic illness or need for a more complex treatment	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.
Regular and Routine Care Visit	Routine, preventive care or services are rendered to avert disease/ illness and/or its consequences, including the diagnosis and treatment of conditions to prevent deterioration to a more severe level.	Appointment is available within 30 business days for follow-up of non- acute symptoms.

Behavioral Health Accessibility Standards (Prescribing and Non-Prescribing)

All care should be given as expeditiously as condition warrants.

Standards	Definition	Scheduled Appointment Time Frame
Emergency Care	An emergency appointment for life- threatening mental health or substance abuse conditions (suicidal intent) or for non-life- threatening mental health or substance abuse conditions that nevertheless necessitate immediate intervention, i.e., psychosis	Directed to the nearest emergency room or call 911.
Care for Non-Life-Threatening Emergency	Services provided for the onset of symptoms of behavioral health problems that require prompt attention but are not considered emergency care. Examples include suicidal/homicidal ideation without a definite 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 the nearest Emergency Department.
Urgent Care Visit	An urgent appointment for an acute mental health or substance abuse condition, or a condition that may become an emergency if not treated, i.e., acute major depression and acute panic disorder.	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	An appointment for specific mental health or substance abuse concerns that are not of an urgent nature, i.e., marital problems, tensions at work, and general anxiety disorder. Excludes follow-up care for an existing problem.	Members are scheduled to be seen within 10 business days of request.
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 business days or as agreed upon by the member and the practitioner.

Accessibility Standards - All

Standards	Definition and Benchmark
Office Wait Time*	Members with appointments should be seen no later than 30 minutes of their scheduled appointment time or arrival time, whichever is later.
After Hours Care* (24-Hour Accessibility)	All network practitioners must be available, either directly or through coverage arrangements, 24 hours a day, 7 days a week. Availability must be by live voice direct to the practitioner or covering practitioner, or via an answering service that can reach the practitioner or covering practitioner. a. Covering provider is expected to be a participating network provider. b. 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 c. After-hours phone response for Urgent problems should be addressed within 60 minutes
Patient No-Show	No-shows for scheduled appointments need to be documented in the patient medical record.

*Applies to all specialists including behavioral health unless otherwise noted

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.

Page last updated on 9/2/2026