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Access, Availability & After-Hours Coverage Standards

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Access, Availability & After-Hours Coverage Standards

ConnectiCare is committed to helping our members stay healthy, get well, and receive health care services in a timely manner. Providers are expected to have procedures in place to see patients within the following time frames and provide 24-hour accessibility as outlined below.

We evaluate our contracted providers’ compliance with these access and availability standards through audits.

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APPOINTMENT WAIT TIMES
TYPE OF APPOINTMENT	TIME FRAME REQUIREMENT
Urgent care	Within 48 hours
Non-Urgent appointments for primary care	Within 10 business days
Non-Urgent appointments for specialist care	Within 15 business days
Non-Urgent for non-physical mental health	Within 10 business days
Non-Urgent for ancillary services	Within 15 business days

24-HOUR ACCESSIBILITY STANDARDS
All network practitioners must be available, either directly or through coverage arrangements, 24 hours a day, 7 days a week, 365 days a year. Availability must be by live voice direct to the practitioner or covering practitioner, or via an answering service that can reach the practitioner or covering practitioner. If an answering machine is used, it must provide an option for the member to directly contact the practitioner or covering practitioner in case of emergencies. An answering machine cannot simply refer the member to an emergency room unless it is a life-threatening issue.

24-HOUR ACCESSIBILITY STANDARDS

All network practitioners must be available, either directly or through coverage arrangements, 24 hours a day, 7 days a week, 365 days a year.
Availability must be by live voice direct to the practitioner or covering practitioner, or via an answering service that can reach the practitioner or covering practitioner.
If an answering machine is used, it must provide an option for the member to directly contact the practitioner or covering practitioner in case of emergencies.
An answering machine cannot simply refer the member to an emergency room unless it is a life-threatening issue.

Tips for ensuring compliance with requirements:

Periodically review the access and availability standards with your appointment schedulers.
Conduct your own secret shopper audits (evaluate a random sample of practices annually).
Monitor practices that did not meet these standards. Implement corrective action plans to ensure compliance.

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Any information provided on this Website is for informational purposes only. It is not medical advice and should not be substituted for regular consultation with your health care provider. If you have any concerns about your health, please contact your health care provider's office.

Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your plan. Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage.