NY Manual
SHP Manual

New York Provider Manual
3.3 Fraud, Waste & Abuse | 3.5 Provider Application Process

3.4 Appointment Availability and 24-Hour Access Standards

Healthfirst maintains provider access, visit scheduling and waiting time standards that comply with New York State requirements. Healthfirst and the NYSDOH actively monitor adherence to these standards (Appendix I). 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.

Office Hours

Each Medicaid, managed care, and CHPlus PCP must practice at least two (2) days per week and maintain a minimum of 16 office hours per week at each primary care site. HIV Specialist PCPs working at academic institutions may have some flexibility with this requirement. Medicare and commercial providers must maintain a minimum of ten (10) office hours per week at each primary care site. Providers who care for the homeless population are not required to maintain a minimum of 16 office hours per week at each primacy care site.

24-Hour Coverage

Participating providers must be accessible 24-hours-a-day, 7-days-a-week throughout the year either directly or through back-up coverage arrangements with other Healthfirst participating providers. Each provider must have an on-call coverage plan acceptable to Healthfirst that outlines the following information:

·     Regular office hours including days, times and locations
·     After-hours telephone number and type of service covering the telephone line (e.g., answering service)
·     Providers who will be taking after-hours calls
·     Facilities as well as individual practitioners must conform to the following requirements:
·     Members will be provided with a telephone number to use for contacting providers after regular business hours. Telephone operators receiving after-hours calls will be familiar with Healthfirst and its emergency care policies and procedures, and will have key Healthfirst telephone numbers available at all times
·     The Healthfirst provider will be contacted and patched directly through to the member, or the provider will be paged and will return the call to the member as soon as possible, but in no case to exceed 30 minutes
·     It is expected that Healthfirst providers will be familiar with Healthfirst and will be able to act in accordance with Healthfirst emergency policies and procedures such as notifying Medical Management of emergency care or admissions. These policies are further discussed in Section 11. Please be aware that hospital-based providers may have their own particular on-call group relationships
·     If the covering provider is not located at the usual site of care for the member, the covering provider must provide clinical information to the member’s PCP by the close of business that day, or if on a weekend, by the next business day so that it can be entered into the member’s medical record

Healthfirst members must be able to locate a Healthfirst participating provider or his/her designated covering provider. It is not acceptable to have an outgoing answering machine message that directs members to the emergency room in lieu of appropriate contact with the provider or covering provider. If an answering machine message refers a member to a second phone number, that phone line must be answered by a live voice.

Waiting Time Standards

In addition to access and scheduling standards, Healthfirst providers are expected to adhere to site-of-care waiting time standards. They are as follows:

Emergency Visits: Members are to be seen immediately upon presentation at the service delivery site

Urgent Care and Urgent Walk-In Visits: Members should be seen within one (1) hour of arrival. Please note that prescription refill requests for medications to treat chronic conditions are considered urgent care. It is essential that these medications be dispensed to members promptly to avoid any lapse in treatment with prescribed pharmaceuticals

Scheduled Appointments: Members should not be kept waiting for longer than one (1) hour

Non-Urgent Walk-In Visits: Members with non-urgent care needs should be seen within two (2) hours of arrival of an unscheduled appointment, or scheduled for an appointment in a time frame consistent with the Healthfirst scheduling guidelines. Providers must have policies and procedures which adequately address enrollees who present for unscheduled, non-urgent care with the aim of promoting enrollee access to appropriate care

Missed Appointments

Healthfirst expects providers to follow up with members who miss scheduled appointments. When there is a missed appointment, providers should follow these guidelines to ensure that members receive assistance and that compliance with scheduled visits and treatments is maintained.

At the time an appointment is scheduled, confirm a contact telephone number with the member. If the member does not keep the scheduled appointment, document the occurrence in the member’s medical record and attempt to contact the member by telephone

To encourage member compliance and minimize the occurrence of “no shows,” provide a return appointment card to each member for the next scheduled appointment