| Criteria |
Standard |
Emergency exam
|
Immediately
When you call the doctor’s office with an emergency medical condition they must arrange for you to be seen right away. They may refer you to the Emergency Room or call 911 |
| Urgent PCP exam |
Within 48 hours
When you contact your doctor’s office with an urgent medical condition we require they see you within 48 hours. We strongly encourage the doctor to work you in on a walk-in basis the same day. If a situation arises where the doctor is not available he or she should refer you to a covering doctor or give you directions on where to be seen within 48 hours. |
| Sensitive Services |
Sensitive services must be made available to you preferably within 24 hours but not to go beyond 48 hours of appointment request. Sensitive services are services related to:
•Sexual Assault
•Drug or alcohol abuse
•Pregnancy
•Family Planning
•Sexually Transmitted Diseases
•Outpatient mental health treatment and counseling
Minors under 21 years of age may receive these services without parental consent. Confidentiality will be maintained in a manner that respects your privacy and dignity. |
| Routine PCP, Non-urgent exam |
Within 10 business Days
When you request an appointment for a routine, non-urgent condition, you must be given an appointment within 10 business days. A routine visit could be a follow-up for blood pressure, diabetes or asthma. |
| Initial prenatal visit to OB/GYN |
Within 7 Calendar Days
You do not need a prior authorization to see an OB/GYN doctor. |
| Well child visits (For child under 2 years of age) |
Within 14 Calendar Days
When a parent requests an appointment for a Well Child Visit they must be given the appointment within 14 calendar days. |
| Preventive care and physical exam |
Within 30 Calendar Days
|
| Initial Health Assessments |
Within 30 calendar days upon request
Care1st suggests you make this appointment within the first 60 days from when you became eligible. Your doctor should ask you to fill out a “Staying Healthy Assessment” form at this appointment. |
| After-hours care |
Doctors are required by contract to give 24 hour, 7 days a week coverage to their patients. The same standards are required by doctors “on-call”. |
| Telephone Access |
Doctors or office staff must return any non-emergency phone calls from you within 24 hours of your call. Urgent and emergent calls must be handled by the doctor or his/her “on-call” coverage immediately. Clinical advice can only be provided by qualified staff (e.g.: physician, physician assistant, nurse practitioner or registered nurse). |
| Waiting Time in office |
30 minutes maximum after time of appointment
|
| Access for Disabled Members |
Care1st audits doctor’s offices every three years to make sure they are following the rules of the Americans with Disabilities Act of 1990. |
| Seldom Used Specialty Services |
Care1st will arrange for seldom used specialty services from specialists outside the network when determined medically necessary. |
| Failed Appointments (Patient fails to show for a scheduled appointment) |
If a patient does not show up for a scheduled appointment, it must be written in the medical record on the day of the missed appointment. The doctor’s office must contact the patient by mail or phone within 48 hours to re-schedule the appointment. If a patient keeps missing appointments, the doctor can refer this issue to the Health Plan for counseling. |
| Criteria |
Standard |
Emergency Care
|
Immediately
When you contact the specialist’s office with an emergency need must contact your doctor right away or direct you to the Emergency Room or call 911 |
| Urgent Specialist Exam |
Within 48 hours
When a doctor refers you for an urgent care need to a specialist (i.e. fracture) they are required to see you within 48 hours or sooner as appropriate from the time the referral was first authorized. |
| Routine specialist visit, Non-urgent exam |
Within 30 Calendar Days |
| After-hours care |
Doctor’s are required by contract to give 24 hour, 7 days a week coverage to members. Doctors “on-call” require the same standards of access and availability. |
| Telephone Access |
Doctor’s or office staff, must return any non-emergency phone calls from you within 24 hours of your call. The doctor or his/her “on-call” coverage must handle urgent and emergent calls immediately. Only qualified staff can give advice (e.g.: physician, physician assistant, nurse practitioner or registered nurse). |
| Waiting Time in office |
30 minutes maximum after time of appointment
|
| Failed Appointments (Patient fails to show for a scheduled appointment) |
Failed appointments must be documented in the medical record and the member’s primary care Practitioner must be notified within 24 hours of the missed appointment. The member must be contacted by mail or phone to reschedule. According to the Practitioner’s office’s written policy and procedure provisions for a case-by-case review of members with repeated failed appointments can result in referring the member to the Health Plan for case management. Practitioners’ offices are responsible for counseling such members. |
