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Access Standards

Horizon Blue Cross Blue Shield of New Jersey has established access standards for our doctors and other health care professionals ("practitioners") to help ensure that members receive the quality care they need when they need it.

Listed below are the various appointment types, their descriptions and the Horizon BCBSNJ standards. The standards apply to the first available appointment1 offered by the practitioners’ office staff from the time you made the request. The standards may vary depending on the member’s medical condition. In certain cases, the office staff may need to see a member earlier than the timeframes listed below.

Primary Care Physician (PCP), Ob/Gyn and Specialist Practitioners Access Standards:

Type of Care Access Standards
Routine Physical Exam2, including annual health assessments, as well as routine gynecological physical exams for new and established members. Except as noted below, the practitioner shall offer other Horizon BCBSNJ members a scheduled appointment as soon as possible, but not to exceed four months of the request.

Practitioners shall offer preventive routine care services to State Health Benefits Program/School Employees’ Benefit Program member within 8 weeks
Routine Care, including any condition or illness that does not require urgent attention or is not life-threatening, as well as routine gynecological care. PCPs and Ob/Gyns
Practitioner shall offer the member a scheduled appointment as soon as possible, but not to exceed two weeks of the request.

Specialists
Practitioner shall offer the member a scheduled appointment as soon as possible, but not to exceed three weeks of the request.
Urgent Care, including medically necessary care for an unexpected illness or injury. Practitioner shall offer the member a scheduled appointment within 24 hours of the request.
Emergent Care, including care for a medical condition exhibiting acute symptoms of sufficient severity including, but not limited to, severe pain; psychiatric disturbances and/or symptoms of substance abuse such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or, with the respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; serious impairment to bodily functions or serious dysfunction of a bodily organ or part. Practitioner shall respond to the member's call immediately and advise as to the best course of action. This may include sending the member to an Emergency Room (ER).
After-hours Care: The hours before or after a practitioner's posted office hours. Practitioner shall have a mechanism to respond to the member’s call for urgent or emergent care that ensures calls in these circumstances are returned within 30 minutes.
Office Waiting Time: The time a member waits to see a practitioner from his/her scheduled appointment time (assuming the member is not late). Members should not be expected to wait long after their scheduled appointment time to see a practitioner.
  • Horizon Medicare Advantage members shall wait no more than 15 minutes from a scheduled appointment time to see a practitioner.
  • Other Horizon BCBSNJ members shall wait no more than 30 minutes from a scheduled appointment time to see a practitioner.

If the waiting time is expected to exceed the above-noted time periods, the office shall offer the member the choice of rescheduling his/her appointment or continuing to wait.

 

Behavioral Health Practitioners Access Standards:

Type of Care Access Standards
Initial Office Visit for Routine Care: An appointment with no extenuating circumstances or sense of urgency. The behavioral health practitioner shall offer the member a scheduled appointment as soon as possible, but not to exceed 10 business days of the request.
Follow-Up Routine Care: An appointment to evaluate member progress and other changes that have taken place since the previous visit. The behavioral health practitioner shall offer the member a scheduled appointment as soon as possible, but not to exceed 30 days of the request.
Urgent: Any request for behavioral health care or treatment that, in the opinion of a practitioner with knowledge of the member’s behavioral health condition, would subject the member to severe pain or distress that cannot be adequately managed without the care or treatment that is the subject of the request. Except as noted below, the Practitioner shall offer other Horizon BCBSNJ members an appointment within 48 hours of the request.

Practitioner shall offer urgent care to Horizon BCBSNJ for State Health Benefits Program/School Employees’ Benefit Program members on the same day or within 24 hours
Non‐life‐threatening Emergency: An appointment for a condition requiring rapid intervention to prevent acute deterioration of the member’s clinical state, such that gross impairment of functioning exists and is likely to result in compromise of the member’s safety. This condition is characterized by sudden onset, rapid deterioration of cognition, judgment or behavior and is time limited in intensity and duration. Practitioner shall offer the member an appointment within six hours of the request or refer member to another participating practitioner, clinic or Emergency Room (ER).
Life‐threatening Emergency: An appointment for a condition requiring immediate intervention to prevent acute deterioration of the member’s clinical state, such that gross impairment of functioning exists and is likely to result in compromise of the member’s safety. This condition is characterized by sudden onset, rapid deterioration of cognition, judgment or behavior and is time limited in intensity and duration. Practitioner shall offer the member an appointment immediately or direct member to an emergency resource (i.e., 911 or the hospital ER).
Medication Adverse Reaction: An appointment for a complaint of an adverse side effect due to medication (prescribing behavioral practitioner only). Practitioner shall offer the member an appointment within 48 hours of the request.
Follow-up Care After Hospitalization: An appointment after discharge from an inpatient psychiatric facility. Practitioner shall offer the member an appointment within seven days of the request.
Office Wait Time: The time a member waits to see a practitioner from his/her scheduled appointment time (assuming the member is not late). Members should not be expected to wait long after his/her scheduled appointment time to see a practitioner.
  • Horizon BCBSNJ Medicare Advantage members shall wait no more than 15 minutes from a scheduled appointment time to see a practitioner.
  • Other Horizon BCBSNJ members shall wait no more than 30 minutes from a scheduled appointment time to see a practitioner.

If the waiting time is expected to exceed the above-noted time periods, the office shall offer the member the choice of rescheduling his/her appointment or continuing to wait.