Policy Number:
n05188
Title:
NHP/NHIC-Plan Standards/Provision of Adequate and Appropriate Access to Care
Abstract Purpose:
Network Health Plan/Network Health Insurance Corporation (NHP/NHIC) has
mechanisms in place to ensure members have timely access to appropriate health and customer care services. NHP/NHIC monitors providers regularly to assure compliance with the established standards contained within this document.
Policy Detail:
Policy
NHP/NHIC will maintain and monitor a network of providers to provide adequate access to covered services in a number sufficient to meet the needs of the population served. NHP/NHIC continuously assesses access to all types of services and modifies the network arrangements as necessary. NHP/NHIC takes corrective action for observed deficiencies, and performs follow-up to determine the effectiveness of the corrective action. The following written standards regarding timeliness of access to health care and member services meet or exceed NCQA and CMS standards.
I. Practitioner Appointment Access Standards
A. Primary Care Physicians- Office and After-Hour Access
1. NHP/ NHIC require primary care physicians to provide access to health care services without excessive scheduling delays. Standards for timeliness of appointments and office waits are made known to the provider network.
2. Practitioners will have policies and procedures in place to properly identify emergency conditions and appropriately triage such cases. Triage
involves identifying those cases which can be managed in the office or must be managed through alternative resources such as immediate care or emergency room service for cases that cannot be safely managed in the office setting. Members requiring emergent care, (defined as life-threatening), will be granted immediate access. Members in need of urgent care, (defined as sudden or recent onset of symptoms that need prompt medical attention), will be seen the same day. Routine and preventive care services will be offered using the third next available appointment methodology, with the maximum time period between a request for an appointment and the date offered as follows:
a. Routine Care (Defined as a symptomatic non-urgent condition that is medically stable): Next calendar day access
b. Preventive Care (Defined as a preventive health evaluation without medical symptoms for existing patients such as an annual physical): Within 21 calendar day’s access.
3. If a practitioner’s schedule cannot accommodate a member’s request for an urgent or routine care appointment within the listed time intervals, an appointment will be offered with an alternate physician, practitioner, nurse practitioner, or physician assistant at the same location. If none of these practitioners are available at the original location, an appointment at another contracted location may be offered with these types of
practitioners. Referral to an Urgent Care/Walk-In Clinic may also be offered as an alternative. The member may choose to decline alternatives and accept a delayed appointment with the practitioner originally
requested.
4. Each PCP clinic site must ensure appropriate processes exist for access to primary care physicians outside of normal business hours. Each NHP/ NHIC PCP will provide 24-hour medical care coverage for members. Acceptable coverage includes the telephone is answered by a clinic staff member, a messaging center/switchboard operator, an answering service, or by an answering machine with instructions on how to obtain access to care. If a recording device is used, clear instructions for obtaining care in emergent and urgent conditions must be included. For all other conditions, one of the following access options must be included in the recorded message:
a. The phone number or pager number of a contracted covering practitioner
b. Affinity NurseDirect’s phone number, or other nurse triage phone line c. Directions to an NHP/ NHIC contracted urgent care center directly
associated with the contracted group. Note: Directing members to the emergency room to obtain all after-hours care is not acceptable. B. Behavioral Health Care Providers
1. NHP/ NHIC require behavioral health practitioners to provide access to health care services without excessive scheduling delays. Standards for timeliness of appointments and office waits are made known to network providers.
2. Practitioners will have policies and procedures in place to properly identify emergency conditions and appropriately triage such cases. Behavioral health practitioners will provide 24-hour medical care coverage for members using the following criteria:
a. *Members requiring emergent care deemed life-threatening will be granted immediate access.
b. *Members requiring emergent care deemed non-life-threatening, will be granted six hour care access.
c. *Members with either life-threatening or non-life-threatening emergencies may be directed to the emergency room
3. Urgent and routine care services will be offered using the next available appointment methodology, with the maximum time period between a request for an appointment and the date offered as follows:
a. Urgent Care –forty-eight hour access b. Routine Care –ten business day access C. Medical Specialty Practitioners
1. Using the third next available appointment methodology, the following types of high volume medical specialists are selected to be available and surveyed for consult or new patient appointment within 21 calendar days:
a. Allergy b. Cardiology c. Dermatology
d. ENT e. Endocrinology f. Gastroenterology g. Neurology h. Neurosurgery i. Hematology/Oncology j. Ophthalmology k. Orthopedics l. Pulmonology m. Rheumatology n. Urology D. OB-GYN Practitioners
1. OB-GYN practitioners will be available for the following services using the third next available appointment methodology:
a. GYN consultation for a new patient: Within 5 calendar days b. Annual GYN exam: Within 21 calendar days
II. Prompt Access to Medical Providers A. Office Hours/Wait Times
1. Practitioners will have appropriate backup for absences.
2. NHP/NHIC requires health care practitioners to have office hours that accommodate the needs of all of its members. These hours should be clearly posted and communicated to members and will not discriminate against Medicare members relative to other members. Office hours should be comparable to other like services in the community.
3. Members have a right to receive timely treatment without unreasonable delays waiting for the practitioner, either in the examination room or the waiting room. However, because of the unpredictable nature of health care needs, delays are sometimes unavoidable. Immediacy of member care needs must be considered.
4. Members can expect the courtesy of being informed when waiting time is anticipated to be more than 30 minutes. Alternatives to waiting should be offered as appropriate.
5. NHP/NHIC requires practitioners are to be readily accessible by
telephone. NHP/ NHIC members have the right to expect courteous and prompt service when contacting their practitioner for appointments or for general information. If communicating about a medical condition, they will speak with an individual who has the training appropriate to address their needs.
B. Telephone Access
1. Response to patient telephone calls will be prompt and reliable. 2. All phones will be answered within 30 seconds of the first ring.
3. Emergency care calls, both weekdays or after-hours, will be dealt with immediately.
4. Urgent care calls, weekdays and after-hours calls, will be responded to within 30 minutes.
5. Routine Care calls will be returned by the end of the day, unless other arrangements are made with the patient.
6. For offices with electronic measurements, call abandonment rate will be less than 5%. If such measurement is not available, very good or excellent satisfaction with access to the office by telephone will be maintained as measured by surveys to be performed by NHP/NHIC.
III. Health Plan Access Standards A. Customer Service Access
1. Medicare Advantage Plan
a. NHIC seeks to provide excellent service to its members through prompt telephone access to Medicare Advantage Customer Service with the following standards of care:
i. Average speed of answer for NHIC Medicare Advantage Member Service, and Care Management Service calls will be 20 seconds or less by a non- recorded voice.
ii. The Medicare Advantage Member Service and Care
Management Service call abandonment rate will be 1.32% or less.
iii. 85% of Medicare Advantage Member Service and Care
Management Service calls will be answered within 30 seconds. 2. Commercial Health Plans
a. NHP seeks to provide excellent service to its members through prompt telephone access to Customer Service with the following standards of care:
i. 85% of NHP Member Service and Medical Care Management calls will be answered within 30 seconds.
ii. Average speed of answer for NHP Member Service and Medical Care Management calls will be 20 seconds or less by a non-recorded voice.
iii. The NHP Member Service and Medical Care Management Service call abandonment rate will be 1.36% or less.
iv. 89% or more of member service issues will be resolved on the first call.
B. Care Management Services Telephone Access 1. Medicare Advantage Plan
a. NHIC seeks to provide excellent service to its members through prompt telephone access to Care Management Services with the following standards of care:
i. Average speed of answer for NHIC Medicare Advantage Care Management Service calls will be 15 seconds or less by a non-recorded voice.
ii. The Medicare Advantage Care Management Service call abandonment rate will be 1.17% or less.
iii. 90% of Care Management Service calls will be answered within 30 seconds.
2. Commercial Health Plan
a. NHP seeks to provide excellent service to its members through prompt telephone access to Care Management with the following standards of care:
i. 89% of Care Management calls will be answered within 30 seconds.
ii. Average speed of answer for Care Management calls will be 15 seconds or less by a non- recorded voice.
iii. The Care Management Service call abandonment rate will be 1.19% or less.
IV. ACCESS MONITORING AND DATA ANALYSIS
A. Using valid methodology, NHP/NHIC collects and performs regular analyses of provider data to measure its performance against standards using the following tools:
1. PCP Appointment Access Survey - a minimum of annually
3. OB-GYN Appointment Access Survey - a minimum of annually
4. Behavioral Health Appointment Access Survey - a minimum of annually 5. After Hours Care Telephone Survey - annually
6. NHP/NHIC Member (Customer) Services telephone indicators - quarterly 7. NHP/NHIC Care Management telephone indicators – quarterly
8. Member satisfaction data analysis- quarterly 9. Access complaints data analysis- quarterly
B. Quality management analyzes and prepares an annual quality program evaluation that includes opportunities and interventions for improvement of access to care. The annual evaluation is presented to NHP/NHIC Quality Management Committee or other leadership groups within NHP/NHIC as deemed appropriate.
C. Practitioners or sites identified for access improvement opportunities will be contacted in a timely manner regarding the survey results, and follow-up measurement may be scheduled. All contracted practitioners are informed of this policy and receive an annual update. The policy is also included on the Network Health web page.
D. Performance falling outside of these standards, with failure to make significant progress in corrective actions, may result in one or more of the following actions:
1. Recommendations from NHP/NHIC to close primary care panel 2. NHP/NHIC contracting with additional practitioners, if needed
3. Adverse credentialing or contracting decisions in cases of persistent failure to make progress toward meeting standards
E. Using valid methodology, NHP/NHIC collects and performs regular analyses of data to measure its member services and behavioral member health services performance against standards with the following measures:
1. NHP/NHIC has continuous, daily electronic monitoring of its member (customer) services and care management member services. Additional analyses are reported quarterly to QMC and annually within the Quality Program Evaluation.
2. Member satisfaction survey data analysis collected annually 3. CAHPS survey results conducted annually
4. Complaints related to access of care (provider or after hour) are
conducted monthly. Anecdotal information is discussed at the Access and Availability Committee meeting which is held at least quarterly and has representation from appropriate departments throughout the health plan.
Regulatory Body:
NCQA CMS
Regulatory Reason:
• QI-5 Element A, B MA-14 Element C, D
• 42 C.F.R. 422.112 (a) (6) (i) and (a) (7); Manual Chapter 4 Section 110.1
Policy Entity:
NHP/NHIC
Policy Discipline:
Origination Date: 10-13-2011 Next Review: 08-01-2014 Approval Information: QMC Approval Date: 10-10-2014
Policy Subject Matter Expert:
Rady , Dawn
drady@networkhealth.com
Network Health Values:
