Appointment Availability Access Standards for Primary Care-Type Providers, ObGyns, Specialists and Behavioral Health Providers

Administrative Policy:

Appointment Availability Access Standards for Primary Care-Type Providers, ObGyns, Specialists and Behavioral Health Providers

Effective Date:

June 2, 2017

Last Revised Date:

December 2, 2023

Scope:

Practitioners that participate in Horizon BCBSNJ's Managed Care Network and/or PPO Network and provide care to fully insured and ASO members.

• Primary care-type providers (e.g., family practitioners, internists and pediatricians)
• Ob/Gyns
• Specialists credentialed in: Cardiology, Dermatology, Endocrinology, Gastroenterology, General Surgery, Neurology, Oncology, Ophthalmology, Optometry, Orthopedic Surgery, and Pulmonology
• Behavioral Health Providers: Psychiatrists, Psychologists, Psychiatric Nurses, Clinical Social Workers, Licensed Professional Counselor (LPC), Licensed Marriage and Family Therapist (LMFT), Licensed Clinical Alcohol and Drug Counselor (LCADC), and Applied Behavioral Analyst (ABA)

For Medicare Advantage members, including Braven Health, only internists and family practitioners may serve as primary care physicians.

Purpose:

To establish access standards for primary care-type practitioners, Ob/Gyns and specialists, define processes for evaluating a random sample of practices annually and for monitoring practices that did not meet our standards.

To define and identify high-volume and high-impact specialties.

Definitions:

High-Volume Specialties – Specialties that are expected to treat a large number of members within a geographic area.

High-Impact Specialties – Specialties that treat conditions that are high risk for mortality and morbidity or where treatment requires significant resources.

APPOINTMENT AVAILABILITY ACCESS STANDARDS FOR PRIMARY-CARE TYPE PROVIDERS, OB/GYNS AND SPECIALISTS:

Routine physical exam: (NCQA)

Including annual health assessments, as well as routine gynecological physical exams for new and established patients.

Except as set forth below, the physician shall offer Horizon BCBSNJ members a scheduled appointment as soon as possible, but not to exceed four (4) months of the request.

Practitioner shall offer a State Health Benefits Program/School Employees' Health Benefits Program member a scheduled appointment as soon as possible, but not to exceed 8 weeks of the request.

Horizon BCBSNJ recognizes that CMS recommends a stricter guideline for preventive care and will monitor response rates to ensure that the majority of our physicians offer an appointment within a 30 day time period.

If we determine that wait times for routine physical exams are exceeding the guidelines, a barrier analysis will be conducted and an action plan will be implemented to improve the wait time.

Symptomatic routine care: (NCQA)

Including any condition or illness that does not require urgent attention or is not life-threatening, as well as routine gynecological care.

The physician shall offer the member a scheduled appointment as soon as possible, but not to exceed two (2) weeks of the request.

Urgent care: (NCQA)

Including medically necessary care for an unexpected illness or injury.

The physician shall offer the member a scheduled appointment within twenty-four (24) hours of the request.

Emergent care:

Including care for a medical condition manifesting itself by 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.

The physician shall respond to the member's call immediately and advise the best course of action. This may include sending the member to an emergency facility.

After-hours care: (NCQA)

The hours before or after a practitioner's posted office hours.

The Physician shall have a mechanism to respond to the members call for urgent or emergent care that ensures calls in these circumstances are returned within thirty (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).

Horizon BCBSNJ Medicare Advantage members shall wait no more than fifteen (15) minutes from a scheduled appointment time to see a practitioner.

Other Horizon BCBSNJ members shall wait no more than thirty (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.

If we determine that a practice is not in compliance with the above-noted wait time standards, a barrier analysis will be conducted and an action plan implemented.

APPOINTMENT AVAILABILITY ACCESS STANDARDS FOR BEHAVIORAL HEALTH PROVIDERS

Follow-up after hospitalization:

An appointment after discharge from an inpatient psychiatric facility.

The behavioral health practitioner shall offer the member a scheduled appointment as soon as possible, but not to exceed seven (7) days of the request.

Initial office visit for routine care visit: (NCQA)

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 ten (10) business days of the request.

Follow up routine care visit: (NCQA)

An appointment to evaluate patient 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 for prescribers and 20 days for non-prescribers.

Urgent care: (NCQA)

Any request for behavioral healthcare or treatment which in the opinion of a practitioner with knowledge of the enrollee's behavioral health condition, would subject the enrollee to severe pain or distress that cannot be adequately managed without the care or treatment that is the subject of the request.

Except as set forth below, the behavioral health practitioner shall offer the member a scheduled appointment within forty-eight (48) hours of the request.

The behavioral health practitioner shall offer the State Health Benefits Program/School Employees' Health Benefits Program member a scheduled appointment within twenty-four (24) hours of the request.

Non-life-threatening emergent care: (NCQA)

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.

The behavioral health practitioner shall offer the member a scheduled appointment within six (6) hours of the request or refer patient to another participating practitioner, clinic, hospital emergency room or Behavioral Health crisis service.

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 his/her scheduled appointment time to see a practitioner.

• Medicare Advantage members shall wait no more than fifteen (15) minutes from a scheduled appointment time to see a practitioner.
• Other members shall wait no more than thirty (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.

If we determine that a practice is not in compliance with the above-noted wait time standards, a barrier analysis will be conducted and an action plan implemented.

Policy:

Horizon BCBSNJ maintains appointment availability standards for offering a first available appointment. The standards outlined in this policy for routine physical exams, routine care, urgent care and emergent care are based on common waiting times for care in the community. The standards for after-hours care and office waiting times are based on what Horizon BCBSNJ determined to be best practice.

These standards are not intended to direct the course of clinical care physicians or behavioral health practitioners provide to a Horizon BCBSNJ member. Nor do these standards replace the independent professional clinical judgment or the practitioner's professional duty to exercise special knowledge and skill in the treatment of patients. As set forth in Horizon BCBSNJ's Agreements, the practitioner remains responsible for the quality and type of health care services provided. A practitioner may need to see a patient earlier than the time frames listed based on the patient's symptoms and/or health history.

The hours of operation for physicians should be convenient and not discriminate against members.

For practitioners that treat Medicare Advantage members: All first tier and downstream entities that contract with Horizon BCBSNJ, a Medicare Advantage Organization (MAO) must comply with our appointment availability standards.

Horizon BCBSNJ annually surveys a random sample of primary care, Ob/Gyn and specialist practices to determine if their first available appointments, after-hours care and office waiting times meet our standards. We expect that each practice meet all of the standards to be considered compliant with this policy. Each surveyed practice will receive a letter requesting an action plan and acknowledgement of receipt of the letter. Surveyed practices that are not compliant will receive a letter requesting a corrective action plan and acknowledgment of receipt of the letter.

Horizon BCBSNJ annually surveys a random sample of Behavioral Health Practitioners to measure compliance with our Behavioral Health Appointment Availability Access Standards outlined above. We expect that each practice meet all of the standards to be considered compliant with this policy. Practices that are not compliant with one or more standards will receive a letter advising on the standards not met. Each surveyed practice will receive a letter requesting an action plan and acknowledgment of receipt of the letter.

The Network Management Department will maintain a database of responses to the following questions and monitor practices that are non-compliant. Any practice with two or more failed NCQA standards will be sent to network specialist for outreach and education. Practices that are repeatedly non-compliant may be referred to the Director of Physician Contracting and Network Operations, who will determine next steps including possible referral to the Quality Peer Review Committee for review and appropriate action.

1. When is your first available appointment for a routine physical exam? (primary care-type providers and Ob/Gyns only)
2. When is your first available appointment for routine care?
3. When is your first available appointment for urgent care?
4. How quickly are members seen for emergent care?
5. Does the practice have a mechanism in place to respond to after-hours phone calls for urgent or emergent care and how long does it generally take for calls to be returned?
6. How many minutes beyond scheduled appointment times do patients wait to see a practitioner?

Any practice with 2 or more failed NCQA standards (excluding non-life threatening emergent care) will be sent to network specialist for outreach and education.

Behavioral Health practices that are repeatedly non-compliant may be referred to the Network Executive and Network Operations, who will determine next steps including referral to the Quality Peer Review Committee for possible action. If there is sufficient evidence that practitioner is actively treating Horizon members, no referral will be made to the credentials committee. The nature of behavioral health services requires longer duration of visits (typically 45-60 minutes for therapy) and members are engaged in ongoing treatment often times for many months and thus practitioners capacity to take on new patients, particularly for urgent appointments, can be limited by their current patient load.

1. When is your first available appointment for follow up after inpatient behavioral health hospitalization?
2. When is your first available appointment for initial routine care?
3. When is your first available appointment for follow up routine care after patient's first visit?
4. When is your first available appointment for urgent care?
5. How quickly are members seen for non-life threatening emergent care?
6. How quickly can a patient be seen that is calling regarding an adverse medication reaction?
7. How many minutes beyond scheduled appointment times do patients wait to see a practitioner?

History:

6/3/2017: Administrative policies PCP, Ob/Gyn and Physician Access Standards (effective since 8/26/11), and Specialist Provider Access Standards (effective since 7/16/93) replaced with the posting of this policy.

12/4/2020: Content of the Behavioral Health Providers Access Standards policy added to this policy content and that separate policy deleted online.

References:

• HMO Regulation N.J.A.C 11:24-6.2(d)(4) and HCQA Regulation N.J.A.C. 11:24A-4.10(b)(1)(iii)
• NCQA - Current Standards and Guidelines for the Accreditation of Health Plans
• Medicare Managed Care Manual, Chapter 4, Section 110.0 “Access and Availability Rules for Coordinated Care Plan”
• 2016 Medicare Part C & D Star Rating Technical Notes
• State Health Benefits Program and School Employees' Health Benefits Program plan requirements effective January 1, 2020.

HCM-PP-HCS-026-1222