Important Information for Practitioners Regarding Timely Access Regulations
On January 17, 2011, the Department of Managed Health Care's Timely Access to Non-Emergency Health Care
Services Regulations ("Timely Access Regulations") became effective. The Timely Access Regulations require
health plans to ensure that health care services are provided to members in a timely manner appropriate for
the nature of the member's condition consistent with good professional practice.
While the Timely Access Regulations impose certain requirements on health plans, practitioners and other providers should be aware of these requirements as set forth below:
|Timely Access Regulations - Appointment Availability Standards|
|Appointment Type:||Offer the Appointment Within:|
|Non-urgent appointments with Primary Care Physicians||10 business days of request|
|Non-urgent appointments with Specialist Physicians||15 business days of request|
|Urgent care appointments that do not require prior authorization||48 hours of request|
|Urgent care appointments that require prior authorization||96 hours of request|
|Non-urgent appointments for ancillary services (for diagnosis or treatment of injury, illness or other health condition)||15 business days of request|
|Non-urgent appointments with a non-physician mental health care provider||10 business days of request|
|Exceptions to the Appointment Availability Standards|
Preventive Care Services and Periodic Follow Up Care: Preventive care services and periodic follow up care are not subject to the appointment availability standards. These services may be scheduled in advance consistent with professionally recognized standards of practice as determined by the treating licensed health care provider acting within the scope of his or her practice. Periodic follow-up care includes but is not limited to, standing referrals to specialists for chronic conditions, periodic office visits to monitor and treat pregnancy, cardiac or mental health conditions, and laboratory and radiological monitoring for recurrence of disease.
Extending Appointment Waiting Time: The applicable waiting time for a particular appointment may be extended if the referring or treating licensed health care provider, or the health professional providing triage or screening services, as applicable, acting within the scope of his or her practice and consistent with professionally recognized standards of practice, has determined and noted in the relevant record that a longer waiting time will not have a detrimental impact on the health of the patient.
Advanced Access: The primary care appointment availability standard listed above may be met if the primary care physician office provides "advanced access." "Advanced access" means offering an appointment to a patient with a primary care physician (or nurse practitioner or physician's assistant) within the same or next business day from the time an appointment is requested (or a later date if the patient prefers not to accept the appointment offered within the same or next business day).