NY Manual
SHP Manual

New York Provider Manual
18 Glossary of Terms | II-A Credentialing Requirements

Appendix I — Appointment Availability and 24-Hour Access Standards

Healthfirst maintains provider access, visit scheduling, and waiting time standards that comply with New York State regulations. Healthfirst and the NYSDOH actively monitor adherence to these standards. Healthfirst conducts audits of provider appointment availability, office waiting times, and 24-hour access and coverage. All participating providers are expected to provide care for their Healthfirst members within these access guidelines.  

Description of Level of Care or Type of Service
Standards
Emergency Care: An emergency condition is defined as a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in placing the health of the person afflicted with such condition in: a) serious jeopardy, impairment, dysfunction, or disfigurement, or b) placing the health of others in serious jeopardy, in the case of a behavioral condition.
Care must be provided immediately upon presentation at the service delivery site.
Urgent Care: Urgent conditions are defined as those illnesses and injuries, of a less serious nature than emergencies, that require services to prevent a serious deterioration of a member’s health and which cannot be delayed without imposing undue risk to the patient’s well-being, until the patient either returns to the Plan’s service area or until the patient can secure services from his or her primary care physician.
Urgent medical or behavioral problems must be seen within 24 hours of request.
Non-urgent “Sick” Visits: These are visits for symptomatic conditions which are neither an emergency nor of an urgent nature. 
Visit must be scheduled within 48-72 hours of request as indicated by the nature of the clinical problem.
Routine Care: These visits are for routine management of clinical conditions or other follow-up care as is clinically appropriate.
Appointment must be scheduled within 4 weeks of request.
Adult Baseline and Routine Physicals
Appointment must be scheduled within 12 weeks of enrollment.
Well-Child Care Visits  
Appointment must be scheduled within 4 weeks of request.
Initial Prenatal Visits:
·         First Trimester
·         Second Trimester
·         Third Trimester 
Appointment must be scheduled within 3 weeks of request.
Appointment must be scheduled within 2 weeks of request.
Appointment must be scheduled within 1 week of request.
Newborn Visits: Initial Visit to the PCP
Appointment must be scheduled within 2 weeks of hospital discharge.
Initial Family Planning Visits  
Appointment must be scheduled within 2 weeks of request.
Non-urgent Referred Specialist Visits  
Appointment must be scheduled within 4 to 6 weeks of request.
In-Plan Behavioral Health or Substance Abuse Follow-up Visits (subsequent to an emergency or inpatient stay) 
Appointment must be scheduled within 5 days or as clinically indicated.
In-Plan, Non-urgent Behavioral Health or Substance Abuse Visits 
Appointment must be scheduled within 2 weeks of request.