Below are our appointment access standards for commercial practitioners, Medicare Advantage providers, and behavioral health and health care clinics.
Below are our appointment access standards for commercial practitioners, Medicare Advantage providers, and behavioral health and health care clinics.
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:
Download our flyer on commercial practitioner access standards.
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:
Access standards for hours of operation
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 |
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:
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:
Medicare Advantage Access Standards for Hours of Operation
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 |
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 |