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
April 5, 2023
PURPOSE
To ensure the availability of medical, mental health/substance use disorder (for applicable covered 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
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/SUD 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.
Initial routine care appointments within ten (10) business 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.
Appointment Standards are also monitored through the complaint process.
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.
Appointment standards will be listed in the Provider Manual.
If a provider is deemed as non-compliant and fails to implement a Corrective Action Plan (CAP) and there are indications of potential FWA this must be reported to SIU or other FWA triage within 10 business days.
PROVIDER COMPLIANCE
Practices that are not compliant with one or more standards will receive a letter advising of the standards not met. Each surveyed practice will receive a letter requesting an action plan and acknowledgement of receipt of the letter. Upon receipt and review of the action plan, Horizon will issue an acceptance letter.
If a provider develops a CAP that is approved, they are re-audited within 3-6 months from the CAP approval letter being sent.
If the provider fails the re-audit, they are referred to the Quality Peer Review Committee, committee reviews the respective case and will recommend a sanction for non–compliance.
If a provider develops a CAP that is not approved, they are educated on the specifications and details needed to develop a successful CAP. They are given 30 days to send in an approved CAP.
If the CAP is approved they are re-audited in 3-6 months from the date the CAP approval letter was sent.
If the provider fails the re-audit, they are referred to the Quality Peer Review Committee, committee reviews the respective case and will recommend a sanction for non–compliance.
If the CAP is not approved for the second time, they are referred to the Quality Peer Review Committee, committee reviews the respective case and will recommend a sanction for non–compliance.
If a provider fails to develop a CAP (after 3 outreach attempts/reminders) they are referred to the Quality Peer Review Committee, committee reviews the respective case and will recommend a sanction for non–compliance.
Behavioral health compliance will focus on providers with 2 or more failed standards with emphasis being on routine access.
Practices that are not compliant with one or more standards will receive a letter advising on the standards not met. Additionally, this letter will request an action plan and acknowledgement of receipt of the letter. Upon receipt and review of the action plan, Horizon will issue an acceptance letter.
Any practice with 2 or more failed NCQA standards (excluding non-life threatening emergent care) will be sent to Behavioral Health Network Specialist for outreach and education.
Behavioral Health practices that are repeatedly non-compliant may be referred to the manager of BH Contracting and Network Relations who will determine next steps including potential referral to the Quality Peer Review Committee for possible action. If there is sufficient evidence that practitioner is actively treating Horizon members, no referral will be made to the credentials committee. The nature of behavioral health services requires longer duration of visits (typically 45-60 minutes for therapy) and members are engaged in ongoing treatment often for many months and thus practitioners' capacity to take on new patients, particularly for urgent appointments, can be limited by their current patient load.
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.
Corrective Action Plan (CAP) – means a plan developed by providers in order to resolve any identified areas of non-compliance with administrative or quality standards.
Level One Administrative Sanction - A Level One Administrative Sanction includes the failure to comply with documented administrative policies, procedures and/or contractual obligations with Horizon BCBSNJ and/or Horizon NJ Health. Level One Administrative Sanctions are tracked internally and are forwarded to the applicable credentialing files, but otherwise do not routinely have any associated penalty attached to them. However, if a provider has multiple Level One or other Sanctions, actions up to and including termination from the provider network could be pursued.
SANCTIONS
Providers who failed the Appointment Availability Audit, Re-Audit or did not submit a Corrective Action Plan, may be issued a Level One Administrative Sanction.
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.
02/21/2023: Added new PROVIDER COMPLAINCE section. Added Corrective Action Plan and Level One Administrative Sanction to DEFINITIONS section. Revised SANCTIONS section content.
03/14/2023: Change made to the “purpose” section for BH providers. Updated 4th sub-bullet under “For MH/SUD appointments” within the Policy: section to include specific wording for routine visit. Added Provider Compliance for BH provider network.
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