Provider Telephone Access Standards Policy Requirements

ADMINISTRATIVE POLICY

Telephone Access Standards Requirements

EFFECTIVE DATE

March 22, 2000

LAST REVIEWED DATE

December 8, 2022

PURPOSE

To ensure that Horizon NJ Health members have twenty-four hours a day, seven days per week, telephone access to providers.

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 Programs (SNP) regulatory and accrediting requirements, and accurately reflects current operations.

This policy will address the Telephone Access Standards located in the NJ Medicaid Managed Care Contract, which stipulate that Horizon NJ Health members will have twenty-four hours a day, seven days per week, telephone access to Horizon NJ Health providers.

Horizon NJ Health will also maintain a twenty-four (24) hour per day, seven (7) day per week toll free answering system that will respond in person, including Telecommunication Device for the deaf (TDD)/Tec telephone (TT) system. Telephone staff shall be adequately trained and staffed and able to promptly advise enrollees of procedures for emergency and urgent care and explain procedures for obtaining non- emergent/non urgent care during regular business hours within the enrollment area as well as outside the enrollment area.

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. Primary Care Providers/Practitioners must provide twenty-four (24) hour, seven (7) day a week telephone access for Horizon NJ Health members.

  2. Response times for telephone call-back waiting times are as follows:

    • After hours telephone care for non-emergent, symptomatic issues – within thirty (30) to forty-five (45) minutes.

    • Same day for non-symptomatic issues.

    • Fifteen (15) minutes for crisis situations.

  3. HNJH will conduct an annual Primary Care Provider (PCP) After-Hours Availability Survey in order to monitor availability and accessibility to PCPs. HNJH will survey, at a minimum, 25% of its PCP network. The PCPs are randomly selected from HNJH provider network file. The PCPs will be contacted after business hours and on weekends.

  4. A telephone response should be considered acceptable/unacceptable based on the following criteria:

    Acceptable:

    • An active provider response, such as: Telephone is answered by PCP, office staff, answering service or voice mail with instructions for contacting the provider.

    • The answering service:

      • Connects the caller directly to the provider/practitioner.

      • Contacts the PCP on behalf of the caller and the provider/practitioner returns the call.

      • Provides a telephone number where the PCP/covering provider/practitioner can be reached.

      • The provider/practitioner's answering machine message provides a telephone number to contact the PCP/covering provider/practitioner.

    Unacceptable:

    • The answering service:

      • Leaves a message for the provider/practitioner on the PCP/covering provider/practitioner's answering machine.

      • Responds in an unprofessional manner.

    • The provider/practitioner's answering machine message:

      • Instructs the caller to go to the emergency room regardless of the exigencies of the situation, for care without enabling the caller to speak with the provider/practitioner for non- emergent situations.

      • Instructs the caller to leave a message for the provider/practitioner.

      • Does not provide an alternative phone number that would connect the patient to the physician/covering provider.

    • No answer.

    • Listed number no longer in service.

    • Provider/practitioner no longer participating in the contractor's network.

    • On hold for longer than (5) minutes.

    • Refuses to provide information for survey.

    • Telephone lines persistently busy despite multiple attempts to contact the provider/practitioner.

  5. HNJH will submit a report of this survey and its corrective action plan to DMAHS annually. HNJH will also include in this report the methodology and sample size used for this survey.

  6. The Professional Contracting and Servicing Departments will monitor provide/practitioner adherence to Twenty-four Hour Access standards.

  7. Twenty-four Hour Access standards will also be monitored through complaints and other relevant satisfaction data.

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) – is a licensed or certified professional who provides medical or behavioral healthcare or services.

Primary Care Provider (PCP) (per state contract)- means a licensed medical doctor (MD) or doctor of osteopathy (DO) or certain other licensed medical practitioner who, within the scope of practice and in accordance with State certification/licensure requirements, standards, and practices, is responsible for providing all required primary care services to enrollees, including periodic examinations, preventive health care and counseling, immunizations, diagnosis and treatment of illness or injury, coordination of overall medical care, record maintenance, and initiation of referrals to specialty providers described in this contract and the Benefits Package, and for maintaining continuity of patient care. A PCP shall include general/family practitioners, pediatricians, internists, and may include specialist physicians, physician assistants, CNMs or CNPs/CNSs, provided that the practitioner is able and willing to carry out all PCP responsibilities in accordance with these contract provisions and licensure requirements.

Member (per state contract) - An enrolled participant in the contractor's plan; also means enrollee.

Member (per NCQA) – A person insured or otherwise provided coverage by a health insurance organization.

Level One Sanction - A Level One Sanction includes the failure to comply with documented administrative policies, procedures and/or contractual obligations with Horizon BCBSNJ and/or Horizon NJ Health. This failure poses a potential harm to the member or unborn child. Level One Sanctions are tracked internally and are forwarded to the applicable credentialing files, but otherwise do not routinely have any associated penalty attached to them.

SANCTIONS

Providers who failed the Appointment Availability re-audit will be issued a Level One Sanction.

EXCEPTIONS

N/A

REFERENCES

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

DMAHS MCO Contract Guidelines; Section 5.11 Telephone Access Policy

HNJH Provider Administrative Manual March 2022; 12.23 After-Hours Coverage

REVISION HISTORY

01/30/2013: Revised certain definitions to reflect State Contract's definition/wording. Revised Policy section: deleted “…no greater than…” added “…within thirty to forty- five….”

11/30/2013: Title changed – Removed Twenty- four Hour. Procedure deleted to create a workflow document number 32C.020.10 WF.

01/22/2015: Revised Provider definition to reflect State Contract's definition. Procedure added back into policy.

01/21/2016: Policy format revised. Revised Provider definition to reflect State Contract's definition. Member definition added to reflect NCQA's definition

01/19/2017: Policy format changed in accordance with internal Horizon policy. Added new approved verbiage to SCOPE AND APPLICABILITY for Horizon lines of business for Government Programs.

01/24/2018: Removed Medigap from lines of business. SCOPE AND APPLICABILITY verbiage related to the Director of Clinical Operations revised and changed to Medical Director III, Quality Management

03/16/2021: Updated Logo and SCOPE AND APPLICABILITY

12/0802022: Added additional unacceptable standard to Section 3.D. Added Level One to Section 5. Added definition of Level One Sanction.

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