Behavioral Health Providers Access Standards

Administrative Policy:
Behavioral Health Providers Access Standards

Effective Date:
March 25, 2011

Last Revised Date:
December 12, 2019

Scope:
Practitioners in the following specialties that participate in Horizon BCBSNJ’s Managed Care Network and/or PPO Network and can provide care to fully insured and ASO members: Psychiatry (MD or DO), Child and Adolescent Psychiatry, Psychology (PhD), Psychiatric Nurse, Social Worker (MSW/ACSW/LCSW), Licensed Professional Counselor (LPC), and Applied Behavioral Analyst (ABA) practitioners who provide behavioral health care services.

Purpose:
To establish access standards for participating behavioral health practitioners’ offices that will be used to measure compliance against these standards.

To 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 Standards for Offering First Available Appointment:

Follow up after hospitalization
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
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
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 care
Except as noted above, 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
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, or hospital emergency room.

Life-threatening emergent care
The behavioral health practitioner shall offer the member an immediate appointment or direct them to an emergency resource, i.e., 911 or the hospital emergency room.

Medication adverse reaction
Access standard: The prescribing behavioral health practitioner shall offer the member a scheduled appointment within forty-eight (48) hours of the request.

Office waiting time
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 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.

Policy:

Horizon BCBSNJ maintains appointment availability standards for offering a first available appointment. The standards outlined in this policy are based on NCQA requirements and what Horizon BCBSNJ determined to be a best practice.

These standards are not intended to direct the course of clinical care that practitioners provide to a Horizon BCBSNJ member. Nor do these standards replace the independent professional judgment or 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 below based on the patient’s symptoms and/or health history.

The hours of operation for behavioral health practitioners 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 surveys practitioners to measure compliance with our appointment availability standards and educates practices that are non-compliant with these standards

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 1/1/2020

HCM-PP-HCS-011-1219