Provider availability: Office location, hours, response time standards

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

Providers must ensure that their office hours for Medicaid and Medicare enrollees are consistent with those for other members.

Standards for our members' accessibility to health care are listed in the charts below. (If a law or regulation is silent on the availability standard requirement it has been noted with an N/A.)

Medical

Prenatal care

Behavioral health

The Priority Health Behavioral Health Department provides information about participating behavioral health care providers to members and other providers. Members seeking services are not required to contact the Behavioral Health department to schedule initial appointments, but our clinicians can, at the member's request, assist members in securing appointments. 

Here are the Priority Health standards for member telephone access to providers and appointment scheduling to ensure timely access of care for members.

Also see:  24-hour access and on-call behavioral health availability standards

Behavioral Health telephone access standards

• Callers reach a non-recorded voice in less than 30 seconds
• The telephone abandonment rate is less than or equal to 5%

Measurement methodology: The telephone system provides data, by telephone queue, for the average speed of answer and the abandonment rates monthly, quarterly, and year-to-date.

Dental

Covering colleague(s)

Priority Health requires providers to name a colleague or colleagues who will be available to Priority Health members if the provider is unavailable for any time beyond the accessibility standards stated here.

Primary care standards

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

• They will be reported 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.

Preventive care/wellness exams   

Available within 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 above.

Measurement methodology: Member satisfaction and complaint monitoring

Medicaid only: Measurement includes all practitioners at the site visited

After hours/24-hour accessibility 

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.

Return calls to members  

During business hours in the same business day

Measurement methodology: Assessed by member satisfaction surveys conducted at least every year.

Office location standards

Offices must meet all local, state and federal zoning and accessibility requirements for businesses.

Standards for offices in residences and non-traditional sites

Offices in residences and other non-related business sites must comply to the following standards.

• A designated office site must be used as a "single purpose" space during established business hours to maintain patient confidentiality.
• A designated office site must be in compliance with local zoning requirements for businesses, and this will be verified as a part of the credentialing process.
• A designated office site must have a dedicated entrance and waiting area and cannot share common space with others (business or residential). There must be a physical separation from other areas not used for business purposes.
• Providers with an office site in a residence, church, or another facility, which serves another function, must demonstrate that they carry general liability insurance in addition to professional liability insurance.