Standards for medical accessibility

Priority Health works with providers to ensure that members have access to care 24 hours a day, 7 days a week.

Primary care standards

The following standards and measurement methodologies apply to primary care physicians and other primary care providers (PCPs) who provide medical services.

• They will be reported quarterly and annually.
• We communicate these standards to practitioners, measure performance against standards, and implement action toward improvements.
• Unless noted, the standards apply to treatment of members of all Priority Health plans.

Go to Behavioral Health Accessibility Standards

1. Emergent care (Medicaid only) available immediately when appropriate and in all cases within 24 hours, or less, depending on the nature of the illness.
   • Examples: Laceration, eye injury, musculoskeletal injury, exacerbation of asthma.
   • Measurement methodology: PCP offices are assessed at the time of the initial credentialing and at triennial recredentialing visit by observing the scheduling book/computer for the first available time. Measurement includes all practitioners at the site visited. Emergency care is also assessed by member satisfaction surveys.
2. Urgent care available within two business days.
   • Examples: High fever or persistent diarrhea and vomiting.
   • Measurement methodology: Assessed by member satisfaction surveys and complaint monitoring.
     Medicaid only: PCP offices are assessed at the time of the initial credentialing and at triennial recredentialing visit by observing the scheduling book/computer for the first available time. Measurement includes all practitioners at the site visited.
3. Symptomatic, non-urgent care (Medicaid Only) available within 4 business days.
   • Examples: Upper respiratory infection, rashes, headaches & joint/muscle pain.
   • Measurement methodology: Assessed by member satisfaction surveys, and at the time of the initial credentialing and at triennial recredentialing visit by observing the scheduling book/computer for the first available time. Measurement includes all practitioners at the site visited.
4. Routine care available within 30 business days (Medicaid 14 business days) for calls made to the office to schedule appointments.
   • Examples: Follow-up appointments for blood pressure checks, diabetes, asthma.
   • Measurement methodology: Assessed by member satisfaction surveys.
     Medicaid only: Each PCP is assessed separately at the time of the initial credentialing and at triennial recredentialing visit by observing the scheduling book/computer for the first available time.
5. Preventive care/wellness exams available within 30 business days (Medicaid 90 business days).
   • Examples: Adult physical exams, well-child visits. Any medical concerns or symptomology expressed by the patient at the time they are scheduling a preventive care/wellness exam should be addressed according to standards 1-4 above.
   • Measurement methodology: Assessed by member satisfaction and complaint monitoring.
     Medicaid only: Each PCP is assessed separately at the time of the initial credentialing and at triennial recredentialing visit by observing the scheduling book/computer for the first available time.
6. After hours/24-hour accessibility is available; phone calls are returned in 2 hours or less.
   • Examples: Answering service, voice mail, answering machine and/or beeper availability.
   • Measurement methodology: Assessed by member satisfaction surveys and complaint monitoring. See the after-hours coverage policy.
     Medicaid only: All PCP offices are called after hours, with triennial recredentialing to verify that they meet Priority Health contract requirements.
   • Return calls to members in 4 hours or less during business hours, depending on the nature of the clinical issue.
     • Measurement methodology: Assessed by member satisfaction surveys conducted at least every other year.
   • Waiting time in the practitioner's office should be an average of no longer than 20 minutes.
     • Measurement methodology: Assessed by member satisfaction surveys conducted at least every other year and complaint monitoring.
   • Member complaints are monitored for dissatisfaction with appointment scheduling, office wait times, and time to return phone calls during and after hours.
     • Measurement methodology: Complaints are monitored through the Quality Concern Committee process, based on member-reported concerns, and reported on a quarterly and annual basis.
   • Member satisfaction with care provided is measured on an ongoing basis for PCPs with 250 or more members and by a member user survey every other year.
   • Reports of accessibility will be provided to Quality Management Committees at least annually. Office and PCP-specific reports are provided to the Credentialing Department prior to triennial recredentialing.