Access to Care Standards

Below are our appointment access standards for commercial practitioners, Medicare Advantage providers, and behavioral health and health care clinics. 

  • Primary care access standards

    Commercial primary care

      Appointment availability
    Urgent (sudden onset of signs or symptoms)  Within 24 hours or refer to urgent care 
    Sick, non-urgent  Within five business days
    Routine health evaluation Within 15 business days 
    Follow-up for chronic condition  Within 30 business days 


    Access standards for primary care include the ability to reach call coverage after hours. 

    We define emergency care as treatment for an injury, illness or condition manifesting itself by acute symptoms of sufficient severity, including severe pain such that a reasonable and prudent layperson could expect the absence of medical attention to result in serious: 

    • Jeopardy to the subscriber’s health 
    • Impairment to bodily function; or 
    • Dysfunction of any bodily organ or part 

    Download our flyer on commercial practitioner access standards. 


    Medicare Advantage primary care

      Appointment availability
    Urgent or emergency services* Immediately 
    Non-urgent or emergency, but requires medical attention Within seven business days 
    Routine, preventative care  Within 30 business days 


    *Emergency medical conditions:     The Centers for Medicare & Medicaid Services defines an emergency medical condition as: 

    A medical condition, mental or physical, manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a reasonable and prudent layperson could expect the absence of immediate medical attention to result in: 

    • Serious jeopardy to the health of the individual or, in case of a pregnant woman, the health of the women or her unborn child; 
    • Serious impairment to bodily function; or 
    • Serious dysfunction of any bodily organ or part. 


    Access standards for hours of operation

    • Hours of operation of providers are convenient to the population served and do not discriminate against Medicare members 
    • Services are available to members 24 hours a day, seven days per week, when medically necessary 

  • Specialty care access standards

    Commercial specialty care for practitioners

      Appointment availability
    In clinic Within one hour waiting time prior to seeing a provider 
    In clinic for behavioral health Within one hour
    Urgent referral Within 24 hours
    Initial referral Within 30 business days

  • Behavioral health and substance use access standards

    Commercial behavioral health and substance use care

      Appointment availability
    Emergency Direction to care available immediately
    Non-life-threatening emergency  Within six hours 
    Urgent Within 24 hours
    Residential care or hospitalization  Within seven days of request 
    Initial visit for routine care  Within 10 business days 
    Follow-up routine care  Within 30 days of request 


    Access standards for behavioral health and substance abuse after hours include:  

    • Access or personal instructions to members 24 hours a day, seven days per week  
    • Instructions to call another number that connects to a person or an office outgoing message that can be returned within one hour  
    • No out of office messages directing members to call 911 or to go to the closest emergency room or urgent care center for services alone, and 
    • All office calls should be answered and must provide instructions per the above requirements.

     

    Medicare Advantage behavioral health and substance use care

      Appointment availability
    Urgent or emergency services*  Immediately
    Non-urgent or emergency, but requires medical attention  Within seven business days
    Routine, preventative care  Within 30 business days 


    *Emergency medical conditions:     CMS defines emergency medical condition as:

    A medical condition, mental or physical, manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a reasonable and prudent layperson could expect the absence of immediate medical attention to result in:

    • Serious jeopardy to the health of the individual or, in case of a pregnant woman, the health of the women or her unborn child;
    • Serious impairment to bodily function; or
    • Serious dysfunction of any bodily organ or part.


    Medicare Advantage Access Standards for Hours of Operation

    • Hours of operation of providers are convenient to the population served and do not discriminate against Medicare member
    • Services are available to members 24 hours a day, seven days per week, when medically necessary 

  • Behavioral health care clinic
      Appointment availability
    Emergency Direction to care available immediately 
    Waiting time in clinic (begins at time of scheduled appointment) Within one hour
    Non-life-threatening emergency Within six hours
    Urgent Within 24 hours
    Non-urgent Within 10 business days
    Outpatient follow-up after hospitalization Within 30 days of request

  • Health care clinic
      Access and availability
    Waiting time (begins at time of scheduled appointment)  Within one hour
    Urgent (suddent onset of signs/symptoms) Within 24 hours or refer to urgent care
    Sick, non-urgent (illness, onset not sudden) Within five business days
    Routine health evaluation Within 15 business days
    Follow-up for chronic condition Within 30 business days