FPMG Access Standards for Medical & Behavioral Health

Transcription

1 FPMG Access Standards for Medical & Behavioral Health FPMG has adopted DMHC Access Regulations 28CCR to address network capacity and availability to offer appointments within specific time frames for Commercial Members Emergency (Serious condition requiring immediate intervention): Immediate (NCQA QI 5.1.4) For Medicare Advantage same. Non-life threatening emergency care within 6 hours. Urgent care appointments for services that do not require prior authorization must offer within 48 hours of the request for appointment. [NCQA QI 5.A.2; 42 CFR (a)(6)(i), (a)(7) (i); 28 CCR (c)(5)(A)]. For Medicare Advantage same. Urgent care appointments for services that require prior authorization must offer within 96 hours of the request of appointment. [NCQA QI 5.A.2; 42 CFR (a)(6)(i), (a)(7)(i); 28 CCR (c)(5)(B)] FPMG Access to Extended Care/ Urgent Care Services After hours care is available 24 hours a day by calling the PCP or FPMG number to reach our answering service who provides emergency care instructions (call 911) and triage to the physician on call for non-emergent matters. The physicians are available 24 hours daily seven days/week. After hours, the Physician On-Call for Family Practice Medical Group will triage members through the normal on-call process. Those members that s/he feels can be treated in an Urgent Care Setting will be directed to: Locations: San Bernardino Medical Group 1700 N. Waterman Ave San Bernardino, CA (909) Ext Extended Care Hours: Monday-Friday 5:00 p.m. - 8:30 p.m. Saturday and Sunday 9:00 a.m. - 4:30 p.m. Holidays 9:00 a.m. - 4:30 p.m. The Primary Care Physician will call the Extended Care Facility to provide the patient s name, reason for presentation, and an authorization number for treatment in order to expedite care delivery. The Extended Care Physician will do the examination and either directs the patient with recommended treatment instructions back to the PCP for follow-up on the next business day, or contact the Physician On-Call should a referral to a specialist or direct admission to an inpatient facility be required. Transcription of Extended Care visits will be faxed directly to the PCP within 48 to 72 hours. Non-urgent: Non-urgent care appointments to a primary care physician: must offer within ten business days of the request of appointment. [NCQA QI 5.A.1; 42 CFR (a)(6)(i), (a)(7)(i); 28 CCR (c)(5)(C)]. For Medicare Advantage 14 calendar days Non-urgent care appointments to a specialist must offer within fifteen business days of the request for appointment. [NCQA QI 5.A.1; 42 CFR (a)(6)(i), (a)(7)(i); 28 CCR (c)(5)(D)]. For Medicare Advantage 14 calendar days.

2 Non-urgent care appointments for ancillary services ( x-rays, lab tests, etc.) for the diagnosis or treatment of injury, illness, or health conditions must offer within fifteen business days of the request for appointment, except as noted below. [28CCR (c)(5)(F)] The applicable waiting time for a particular appointment may be extended if the referring or treating licensed health care provider, or the health professional providing triage or screening services, as applicable, acting within the scope of his or her practice and consistent with professionally recognized standards of practice, has determined and noted in the relevant record that a longer waiting time will not have a detrimental impact on the health of the member. The determination may be made only by the referring or treating licensed health care provider, not by office staff/schedulers. This is applicable to all urgent and non-urgent appointments above. [28 CCR (c)(5)(G)] Preventive Care Services and periodic follow-up care including but not limited to, standing referrals to specialists for chronic conditions, periodic office visits to monitor and treat pregnancy, cardiac or mental health conditions, and laboratory and radiological monitoring for recurrence of disease may be scheduled in advance as long as it is consistent with professionally recognized standards of practice as determined by the treating licensed health care provider acting within the scope of his or her practice. These services are not subject to the appointment availability standards. These services include, but are not limited to standing referrals to specialists for chronic conditions, periodic office visits to monitor and treat pregnancy, cardiac or mental health conditions, and laboratory and radiological monitoring for recurrence of disease. [28 CCR (c)(5)(H)] For Medicare Advantage: 60 calendar days. Behavioral Health Access Standards (Commercial & Senior) Life Threatening Emergency: Immediately Non-Life Threatening Emergency: Behavioral Healthcare appointment within 6 hours. [NCQA QI 5.B.1] Urgent Care: Urgent Behavioral Healthcare must offer appointment within 48 hours. [NCQA QI 5.B.2] Routine Office (Non-Urgent) Visit for Behavioral Healthcare Physician must offer appointment within 10 business days of the request. [NCQA QI 5.B.3; 28 CCR (c)(5)(e)] Non-Urgent appointment with a physician or non-physician mental health provider must offer within 10 business days of the request except as noted above. Follow up care after hospitalization for mental illness will include one follow up encounter with a mental health provider within 7 calendar days after discharge plus one follow up encounter within 30 calendar days after discharge. Medi-Cal Non-Emergent Medical Appointment Access Standards: Currently N/A Access to PCP or designee: 24 hours a day, 7 days a week. Non-urgent Care appointments for Primary Care (PCP Regular and Routine, excludes physicals and wellness checks) must offer the appointment within 7 business days of request. Adult physical exams and wellness checks must offer the appointment within 30 calendar days of request. Non-urgent appointments with Specialists physicians (SCP Regular and Routine) must offer the appointment within 15 business days of the request.

3 Urgent Care appointments that do not require prior authorization (includes appointment with any physician, Nurse Practitioner, Physician s Assistant in office) must offer the appointment within 24 hours of request. Urgent Care appointments that require prior authorization (SCP) must offer appointment within 96 hours of request. First prenatal visit must offer the appointment within 5 business days of request. Child physical exam and wellness checks with PCP must offer the appointment within 10 business days of request. Non-urgent appointments for ancillary services (diagnosis or treatment of injury, illness, or other health condition) must offer the appointment within 15 business days of request. Initial Health Assessment (enrollees age 18 months and older) must be completed within 120 calendar days of enrollment. Initial Health Assessment (enrollees age 18 months and younger) must be completed within 60 calendar days of enrollment. Office Wait Time for scheduled appointments: Not to exceed 15 minutes Extending Appointment Waiting Time: The applicable waiting time for a particular appointment may be extended if the referring or treating licensed health care provider, or the health professional providing triage or screening services, as applicable, acting within the scope of his or her practice and consistent with professionally recognized standards of practice, has determined and noted in the relevant record that a longer waiting time will not have a detrimental impact on the health of the enrollee. Appointment Rescheduling When it is necessary for a provider or enrollee to reschedule an appointment, the appointment shall be promptly rescheduled in a manner that is appropriate for the enrollee s health care needs, and ensures continuity of care consistent with good professional practices and consistent with the objectives of this policy. Telephone Access After Hours & Weekend Care: At a minimum, FPMG will have health professionals available by phone outside of business hours, which includes 24 hours/day seven days/week via telephone with a triage period return call from provider not to exceed 30 minutes. NCQA QI 5.A.3; 42 CFR (a)(6)(i); (a)(7)(ii); 28 CCR (c)(8)] Caller may also call administrative office for another provider who has agreed to be on-call to triage or screen by phone, or if needed, deliver urgent or emergency care. After hours answering services or telephone system will include a message immediately stating If this is an emergency, hang up and call 911 or go to the nearest emergency room. FPMG is responsible for the service it uses. If an enrollee calls after hours or on a weekend for a possible medical emergency, FPMG is held liable for the authorization of or referral to emergency care given by the answering service. [42 CFR (b)(iii)(2)(B)(iv); 28 CCR (c)(8)(B)] Telephone logs will be monitored and maintained by the answering service. After hours calls will be documented in the patient record by office staff.

4 Telephone services availability for Medical & Behavioral Health: Telephone triage or screening services are provided in a timely manner appropriate for the member s condition and the triage or screening waiting time does not exceed 30 minutes. [28 CCR (c)(8)(A)] The answering service and/or office staff will inform the caller: Regarding the length of the wait for a return call from the provider (not to exceed 30 minutes); and How the caller may obtain urgent or emergency care including, when applicable, how to contact another provider who has agreed to be on call to triage or screen by phone, or if needed, deliver urgent or emergency care. Answering service/office staff handling enrollee calls cannot provide telephone medical advice if they are not a licensed, certified or registered health care professional. Staff members may ask questions on behalf of a licensed professional in order to help ascertain the condition of the enrollee so that the enrollee can be referred to licensed staff; however, they are not permitted, under any circumstance, to use the answers to questions in an attempt to assess, evaluate, advise, or make any decision regarding the condition of the enrollee, or to determine when an enrollee needs to be seen by a licensed medical professional. Unlicensed telephone staff should have clear instructions on the parameters relating to the use of answers in assisting a licensed provider. Additionally, non-licensed, non-certified or non-registered health care staff cannot use a title or designation when speaking to an enrollee that may cause a reasonable person to believe that the staff member is a licensed, certified or registered health care professional. The answering service will document all calls. Assessment occurs directly at the treatment source, not through central triage Adequate telephone service staff is available for calls for member services, questions, and problems during business days/hours 8:30-5:00 daily with a wait time to speak with a member services representative no longer than 10 minutes. [NCQA QI 5.A.4; 42 CFR (a)(7)(ii)] Behavioral health telephone service Applicable to phone triage lines: N/A currently Call Wait Times: <30 Seconds to be answered by a non-recorded voice Call Abandonment Rate quarterly average: Within 5% Telephone Advice Service: Telephone Advice Services (currently offered only by PCPs on call & Health Plan Services) Currently N/A except by physician Current registration with the State Department of Consumer Affairs renewed every 2 years. All participating practitioners will be licensed, registered, or certified in the state they are providing the telephone medical advice services, and operating consistent with the laws governing their respective scopes of practice. (Physician only) Staff members handling member calls, who are not licensed, certified, or registered as required, will not provide telephone medical advice. Staff members may ask questions on behalf of a licensed professional in order to help ascertain the condition of the enrollees so that the member can be referred to licensed staff; however, they are not permitted under any circumstance, to use the answers to questions in an attempt to assess, evaluate, advise or make any decision regarding the condition of the member, or to determine when a member needs to be seen by a licensed medical professional. Unlicensed telephone staff should have clear instructions on the parameters relating to the use of answers in assisting a licensed provider.

5 No staff member will use a title or designation when speaking to a member that may cause a reasonable person to believe that the staff member is a licensed, certified or registered professional. A physician and surgeon will be available to the telephone medical advice service on an oncall basis at all times the service is advertised to be available. Advice will be consistent with good professional practice. A complaint tracking and reporting system will be implemented. The answering service should document all calls. Transcripts of telephone advice service conversations and copies of complaints will be retained for 5 years.