QUALITY IMPROVEMENT & PATIENT CARE
Appointment Access Standards: Ensuring Timely Care for Members
We are dedicated to ensuring our members have timely access to the services they need. Providers participating in one or more of our networks are expected to ensure members have access to timely care by complying with the Access Standards below. These standards are established by the Centers for Medicare & Medicaid Services (CMS), the State of Utah, and per the Federal Register Qualified Health Plan requirements.
The following Appointment Access Standards are established in our Provider Manual. Please review these standards with the appropriate staff and incorporate any changes to your business practices as may be warranted.
Appointment Wait Times
Note: A PCP is defined as a generalist in any of the following areas: Family Practice, General Practice, General Internal Medicine, Obstetrics/Gynecology (by physician), and Pediatrics.
Urgent Care
Symptomatic, not life-threatening, treated in a provider’s office. Does not indicate dangerousness, but the patient’s functioning is seriously impaired and symptoms are moderate to severe.
| Provider Type | Access Standard |
|---|---|
| Primary Care Provider | Within 48 hours (2 days) |
| Specialty Care Provider | Within 48 hours (2 days) |
| Behavioral Health Provider | Within 48 hours (2 days) |
Routine, Non-Urgent Care
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Does not apply to appointments for regularly scheduled visits to monitor a chronic condition if the schedule calls for visits less frequently than once per month.
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Includes school physicals.
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Includes symptoms generally less intrusive and less serious than those requiring urgent care.
| Provider Type | Access Standard |
|---|---|
| Primary Care Provider | Within 30 days |
| Specialty Care Provider | Within 30 days |
| Behavioral Health Provider | Initial visit for routine care: Within 10 business days Follow-up routine care: Within 30 days |
After-Hours Care
Providers must offer after-hours care or provide directions on where members can receive after-hours care.
Initial Contact Requiring Emergency Services (Behavioral Health Services only)
Initial contact includes by telephone or on a walk-in basis.
Screening within 30 minutes of initial contact:
- Face-to-face appointment within 1 hour if determined to be an emergency
- Face-to-face appointment within 5 business days if determined to be urgent
- Face-to-face appointment within 15 business days if determined to be non-urgent
Note: Medicaid members must be offered appointments during the same hours of operation offered to commercial group and individual/family plan members or Medicaid fee-for-service members.
Appointment Scheduling
Providers are required to have an appropriate scheduling system that reserves adequate time allotments for various types of appointments, as well as adequate time reserved for urgent or acute care. The provider’s telephone system must be sufficient to manage the volume of calls coming in to the office.
View the Appointment Access Standards Policy in its entirety in our Provider Manual.