Appointment Availability Access Standards for Primary Care-Type Providers, Ob/Gyns, Specialists and Behavioral Health Providers

ADMINISTRATIVE POLICY

NJ Health Appointment Availability Access Standards for Primary Care-Type Providers, Ob/Gyns, Specialists and Behavioral Health Providers

EFFECTIVE DATE

March 22, 2000

LAST REVIEWED DATE

March 15, 2022

PURPOSE

To ensure the availability of medical, mental health/substance abuse (for DDD Clients and MLTSS members) and dental care appointments for Horizon NJ Health members.

SCOPE AND APPLICABILITY

This policy was developed in accordance with applicable Centers for Medicare and Medicaid Services (CMS) guidelines, the NJ Medicaid Managed Care Contract, applicable NJ State and Federal Guidelines, and national accreditation standards. This policy will be reviewed annually, revising procedures as necessary to reflect changes to specific guidelines. The annual review of this policy and procedure shall ensure that it is still relevant and compliant with appropriate New Jersey State and Federal Medicaid, Medicare Advantage and Special Needs Program (SNP) regulatory and accrediting requirements, and accurately reflects current operations.

This policy will address the Appointment Availability standards located in section 5.12 of the NJ Medicaid Managed Care Contract that all Horizon NJ Health medical, mental health/substance abuse and dental providers must adhere to.

This policy applies to the Medicaid/NJ FamilyCare and Fully Integrated Dual Eligible Special Needs (“FIDE-SNP”) plans issued and/or administered by Horizon Healthcare Services, Inc. d/b/a Horizon Blue Cross Blue Shield of New Jersey and/or its affiliates, including Horizon Healthcare of New Jersey, Inc. d/b/a Horizon NJ Health (collectively “Horizon”).

POLICY

  1. All practitioners, providers and facilities will adhere to the following appointment standards:

    • Emergency Services. Immediately upon presentation at a service delivery site.

    • Urgent Care. Within twenty-four hours. An urgent, symptomatic visit is an encounter with a health care provider associated with the presentation of medical signs that require immediate attention, but are not life-threatening.

    • Symptomatic Acute Care. Within seventy-two (72) hours. A non-urgent, symptomatic office visit is an encounter with a health care provider associated with the presentation of medical signs, but not requiring immediate attention.

    • Routine Care. Within twenty-eight (28) days. Non-symptomatic office visits shall include but shall not be limited to: well/preventive care appointments such as annual gynecological examinations or pediatric and adult immunization visits.

    • Specialist Referrals. Within four (4) weeks or shorter as medically indicated. A specialty referral visit is an encounter with a medical specialist that is required by the enrollee’s medical condition as determined by the enrollee’s Primary Care Provider (PCP). Emergency appointments must be provided within 24 hours of referral.

    • Urgent Specialty Care. Within twenty-four (24) hours of referral.

    • Baseline Physicals for New Adult Enrollees. Within one hundred-eighty (180) calendar days of initial enrollment.

    • Baseline Physicals for New Children Enrollees and Adult Clients of DDD. Within ninety (90) days of initial enrollment, or in accordance with EPSDT guidelines.

    • Prenatal Care. Enrollees shall be seen within the following timeframes:

      • Three (3) weeks of a positive pregnancy test (home or laboratory)

      • Three (3) calendar days of identification of high risk

      • Seven (7) days of request in first and second trimester

      • Three (3) calendar days of first request in third trimester

    • Routine Physicals. Within four (4) weeks for routine physicals needed for school, camp, work or similar.

    • Lab and Radiology Services. Three (3) weeks for routine appointments; forty-eight (48) hours for urgent care.

    • Waiting time in office. Less than forty-five (45) minutes.

    • Initial Pediatric Appointments. Within three (3) months of enrollment.

    • For dental appointments:

      • Emergency dental treatment no later than forty-eight (48) hours, or earlier as condition warrants, of injury to sound natural teeth and surrounding tissue and follow-up treatment by a dental provider.

      • Urgent care appointments within three (3) calendar days of referral.

      • Routine non-symptomatic appointment within thirty (30) days of referral.

    • For MH/SA appointments:

      • Emergency services immediately upon presentation at a service delivery site.

      • Non life-threatening emergent within six (6) hours of the request or refer patient to another participating practitioner, clinic, or hospital

      • Urgent care appointments within twenty-four (24) hours.

      • Routine care appointments within ten (10) days of request.

      • Follow-up routine care as soon as possible, but not to exceed 30 days for prescribers and 20 days for non-prescribers.

    • Maximum Number of Intermediate/Limited Patient Encounters. Four (4) per hour for adults and four (4) per hour for children.

    • For SSI and New Jersey Care – ABD elderly and disabled enrollees, each new enrollee or, as appropriate, authorized person is contacted to offer an Initial Visit to the enrollee's selected PCP. Each new enrollee shall be contacted within forty-five (45) days of enrollment and offered an appointment date according to the needs of the enrollee, except that each enrollee who has been identified through the enrollment process as having special needs shall be contacted within 10 business days of enrollment and offered an expedited appointment.

  2. Appointment Standards are also monitored through the complaint process.

  3. Monitoring of Dental will be the responsibility of the delegated vendor contracted for these services and results will be reported through delegate oversight by the Quality Management Department.

  4. Appointment standards will be listed in the Provider Manual.

  5. If a provider is deemed as non-compliant and fails to implement a Corrective Action Plan and there are indications of potential FWA this must be reported to SIU or other FWA triage within 10 business days.

DEFINITIONS

Provider (per state contract) - means any physician, hospital, facility, health care professional or other provider of enrollee services who is licensed or otherwise authorized to provide services in the state or jurisdiction in which they are furnished.

Practitioner (per NCQA) - a licensed or certified professional who provides medical or behavioral healthcare services.

Division of Developmental Disabilities (DDD) (per state contract) - A division within the New Jersey Department of Human Services that provides evaluation, functional and guardianship services to eligible persons. Services include residential services, family support, contracted day programs, work opportunities, social supervision, guardianship, and referral services.

Early and Periodic Screening, Diagnosis and Treatment (EPSDT) (per state contract) - a Title XIX mandated program that covers screening and diagnostic services to determine physical and mental defects in enrollees under the age of 21, and health care, treatment and other measures to correct or ameliorate any defects and chronic conditions discovered, pursuant to Federal Regulations found in Title XIX of the Social Security Act.

Managed Long Term Services and Supports (MLTSS) (per state contract)-A program that applies solely to individuals who meet MLTSS eligibility requirements and encompasses the NJ FamilyCare A benefit package, NJ FamilyCare ABP (excluding the ABP BH/SA benefit) as specified in Article 4.1.1.C, HCBS and institutionalization for long term care in a nursing facility or special care nursing facility.

Days (per State Contract)- calendar days unless otherwise specified.

SANCTIONS

Practices that are repeatedly non-compliant will also be referred to the Director of Physician Contracting and Network Operations that will determine next steps including referral to the Credentials Committee and appropriate administrative provider sanctions will be enforced.

EXCEPTIONS

N/A

REFERENCES

NCQA - Current Standards and Guidelines for the Accreditation of Health Plans

DMAHS MCO Contract Guidelines; Section 5.12 Appointment Availability; Section 5.13 Appointment Monitoring Procedures

HNJH Provider Administrative Manual March 2022; Section 12.18 Appointment Scheduling Standards

REVISION HISTORY

01/21/2017: Added wording to POLICY to clarify timelines for appointment availability for prenatal care & dental appointments. Revised Practitioner definition to reflect NCQA's definition. Clarified source of MLTSS definition (per state contact). Added Days definition to reflect State Contract's definition

01/25/2017: Revised dates for current review and next annual review. Added verbiage to SCOPE for Horizon lines of business for Government Programs

01/24/2018: Removed Medigap from lines of business.

03/17/2020: Updated to reflect change in reporting of MH/SA from delegate vendor to HNJH. Wording added to reflect FWA/SIU referral requirement noted in Medicaid Managed Care Contract 4

03/16/2021: Update logo and SCOPE.

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