After-Hours Policy

Practitioner accessibility to members after normal business hours is a key indicator of quality of care and service promoted by the National Committee for Quality Assurance, the Michigan Department of Community Health and purchasers of health care.

To ensure that appropriate care is extended to members beyond business hours, Priority Health requires:

1. Methods:
All Priority Health contracted Practitioners will have appropriate after-hours coverage utilizing one of the following methods:

• Answering service that will contact practitioners on behalf of the member.
  
  
• Answering machine with explicit directions (including other telephone numbers if necessary) on how to reach a practitioner and action to take in an emergency. The practitioner may ask the member to leave a message but must be able to respond in an expedient manner.
  
  
• For rural* Primary Care Practitioners (PCPs), an answering machine may direct the member to call an emergency room in order to have the opportunity to be directed to a covering practitioner. The instructions must clearly direct the member with non-emergent situations to call the emergency room first and provide the member the telephone number(s) of the emergency room(s) available in the area.
  *Rural service areas include the following counties: Antrim, Barry, Benzie, Charlevoix, Cheboygan, Crawford, Eaton, Emmet, Grand Traverse, Gratiot, Ionia, Kalkaska, Lake, Leelanau, Manistee, Mason, Mecosta, Montcalm, Montmorency, Newaygo, Oceana, Osceola, Otsego, and Wexford.
  
  
• For Specialty Care Practitioners (SCPs), for which no other like in-network practitioner is available to share call, an answering machine may direct the member to call their Primary Care Practitioner or an emergency room in order to have the opportunity to be directed to a covering practitioner. The instructions must clearly direct the member with nonemergent situations to call their Primary Care Practitioner or emergency room first and provide the member the telephone number(s) of the emergency room(s) available in the area.
  
  
• Certain types of specialty practices that do not typically incur emergent situations or individual circumstances may be exempt from this requirement. Certain specialties include, but may not be limited to: pathology, dermatology, infectious disease, optometry, chiropractic, etc. Individual circumstances will be taken into account, i.e., certain types of specialty practices, for final compliance determination.
  

2. Compliance:
The determination of compliance, in unique or questionable circumstances, will be made by the Director of Corporate Quality Improvement, Medical Director(s), and/or Chief Medical Officer as necessary.

3. Enforcement:
Practitioners who are not compliant to the Administrative standard will be notified of the need to improve after-hours access, by letter, requesting a response within three months of initial contact. A follow-up random after hours call will confirm action or non-action taken by the practitioner. Further non-compliance will result in a second letter and continued non-compliance will result in further review by Medical Affairs or Credentialing Committees with potential sanctions implemented.

4. Monitoring:
Application for credentialing, member complaints, office site visits or contacts.