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 Emergency Care

Example: Major trauma injury; 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, children with ear pain and fever
Appointment available within 24 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 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 problems
Appointment available within 30 days for follow-up of non-acute symptoms.
Preventive Care Example: Well-child visits, routine physical or gynecological exams Appointment is available within 30 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-hours-a-day, 7-days-a-week 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 must be a participating network provider.

After-hour answering machine must include:1) Urgent/Emergent instructions as first point of instruction. 2) Information on contacting a covering provider and 3) 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.

Specialist Accessibility Standards

All care should be given as expeditiously as condition warrants.

Type of Service  Description  Performance Goal 
Emergency Care Emergency Care
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.
Appointment available within 24 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 symptoms or health problems requiring prompt but not immediate medical attention.
Regular and Routine Care Follow-up care for non-acute symptoms.
Appointment available within 30 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-hours-a-day, 7-days-a-week 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 must be a participating network provider

After-hour answering machine must include:1) Urgent/Emergent instructions as first point of instruction. 2) Information on contacting a covering provider and 3) 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

All care should be given as expeditiously as condition warrants.

Type of Service  Description  Performance Goal 
Emergent/Immediate Emergent/immediate

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 Example: minor trauma injury, signs/symptoms of urinary tract infection, vaginal infection Appointment is available within 24 hours of initial request.
Routine Care Example: gynecological exams, renewal of oral contraceptives Appointment is available within 2 months.
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:1) Urgent/Emergent instructions as first point of instruction. 2) Information on contacting a covering provider and 3) 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

All care should be given as expeditiously as condition warrants.

Type of Service  Description  Performance Goal 
Emergency Care Emergency care 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.
Appointment 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 Appointment available within 30 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-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:1) Urgent/Emergent instructions as first point of instruction. 2) Information on contacting a covering provider and 3) 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.

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.