New Claims System Update

4.1 Access and Availability Standards

Provider Manual
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4 ACCESS TO CARE

4.1 Access and Availability Standards

Participating IntegraNet providers must:

  • Provide coverage for members 24 hours a day, 7 days a week.
  • Ensure another on-call IntegraNet provider is available to administer care when the PCP is not available.
  • Should not substitute hospital emergency rooms or urgent care centers for covering providers.
  • See members within 30 minutes of a scheduled appointment or inform them of the reason for delay (e.g., emergency cases) and offer an alternative appointment.
  • Provide an after-hours telephone service to ensure a response to emergency phone calls within 30 minutes and a response to urgent phone calls within one hour; individuals who believe they have an emergency medical condition should be directed to immediately seek emergency services from the nearest emergency facility.
    • Type of appointment
    (medical or behavioral)    		 Availability standard
    Patient visit with new PCP Within 30 calendar days
    Routine follow-up or preventive care As soon as possible but within 30 calendar days
    Routine/symptomatic Within 7 days
    Nonurgent care Within 7 days
    Urgently needed services Within 24 hours
    Emergency Immediately

    IntegraNet monitors adherence to appointment availability standards through office visits, long-term care visits, and tracking of complaints and grievances related to access and/or discrimination. Deviations from the policy are reviewed by the medical director for educational and/or counseling opportunities and tracked for provider recredentialing.

    Providers and hospitals are expected to treat all plan members with the same dignity and consideration as afforded to their non-Medicare patients.