Ch 12: Timely Access Requirements

VHP and DMHC have established expectations and standards regarding provider accessibility. These expectations and standards help VHP’s members obtain appointments and receive services within specific required timeframes. All providers are required to adhere to the timely access standards set forth below.

Timely Access Standards Primary Care Providers (PCPs)

Appointment Type or Service Criteria Standard Access Timeframe

Urgent Appointment

Immediate care is not needed for stabilization, but if not addressed in a timely way could escalate to an emergency. Appointment offered within 48 hours of request.

Non-Urgent/Routine Appointment

Immediate care is not needed. For example, this appointment type could be related to new health issues or a follow-up appointment for existing health problems. Appointment offered within10 business days of request.

Specialists

Appointment Type or Service Criteria Standard Access Timeframe

Urgent Appointment

Immediate care is not needed for stabilization, but if not addressed in a timely way could escalate to an emergency. Appointment offered within 96 hours of request.

Non-Urgent/Routine Appointment

Immediate care is not needed. For example, this appointment type could be related to new health issues or a follow-up appointment for existing health problems. Appointment offered within15 business days of request.

p.91

2021 / Provider Manual

Appointment Type or Service

First Prenatal Visit Criteria

Immediate care is not needed.

Standard Access Timeframe

Appointment offered within 2 weeks of request.

Behavioral Health Providers

Appointment Type or Service Criteria Standard Access Timeframe

Non-Life-Threatening Emergency Appointment

Urgent Appointment

Immediate assessment or care is needed to stabilize a condition or situation, but there is no imminent risk of harm to self or others.

Immediate care is not needed for stabilization, but if not addressed in a timely way could escalate to an emergency. Appointment offered within 6 hours of request.

Appointment offered within 48 hours of request.

Routine (Non-Urgent) Appointment

An assessment of care is required with no urgency or potential risk of harm to self or others. Appointment offered within 10 business days of request.

Follow Up Routine Appointment

Follow-up care is required for nonurgent/routine care. Appointment offered within 30 business days of request.

Other Provider Types and Facilities

Appointment Type or Service Criteria Standard Access Timeframe

Appointment Type or Service

Criteria Standard Access Timeframe

Ancillary

Diagnosis or treatment of injury, illness, or other health condition. Appointment offered within 15 business days.

p.92

2021 / Provider Manual

Pharmacy

Skilled Nursing Facility (SNF)

Intermediate Care Facility (ICF)

Dispensing of a covered outpatient drug in an emergency. Provide at least a 72-hour supply of a covered outpatient drug.

Patient’s functional or medical complexity are such that the outcome would be compromised with less than daily skilled services. Provide service within 5 business days.

Services for developmental disabilities. Provide service within 5 business days.

After-Hours Accessibility

Services

Automated System, Office, or Exchange/Answering Services Standard Access Timeframe

Must inform the member that the provider will call back within 30 minutes.

Life-Threatening Situation

Urgent Need to Speak with a Provider

Automated system must provide emergency 911 instructions, such as: • “Hang up and dial 911 or go to the nearest emergency room.” Behavioral Health providers should include the number to the Santa Clara County Suicide and Crisis Hotline: • “Hang up and dial 911 or go to the nearest emergency room or call the crisis hotline at 1.855 278.4204.”

Automated system, office, or exchange/answering services must connect the member with an on-call provider or should direct the member on how to contact a provider after hours.

Exceptions to Time-Elapsed Standards

1. The waiting time for a particular appointment may be extended if the referring provider, or health professional, providing triage and screening services, and acting within the scope of practice, consistent with professionally recognized standards of practice, has determined and noted in the medical record that a longer waiting time will not have a detrimental impact on the health of the member.

p.93

2021 / Provider Manual

2. Preventive care services and periodic follow-up care, including standing referrals for chronic conditions, periodic office visits for pregnancy, cardiac or mental health conditions, laboratory and radiological monitoring for recurrence of disease, may be scheduled in advance consistent with professionally recognized standards of practice as determined by the treating health care provider acting within the scope of practice.

3. Compliance with primary care time-elapsed standards can be made through an advanced access scheduling system, which is designed to improve patient access to care by eliminating barriers to such care.

Triage and Screening Services

A provider’s triage and screening services offered by telephone must be provided in the following manner: 1. 24 hours per day, seven days a week by a qualified, licensed health professional. 2. Ensure triage and screening services are provided in a timely manner appropriate to the member’s condition. 3. The wait time for triage and screening services does not exceed 30 minutes. 4. Provide a procedure which includes during and after business hours, a telephone answering machine, or answering service, and/or office staff that will inform the caller regarding the following: a. Wait time for a return telephone call, which shall not exceed 30 minutes; b. Instructions regarding obtaining urgent or emergency care, including, when applicable, how to contact another provider who has agreed to provide on-call coverage; and c. In no case shall unlicensed staff use a member’s answers to questions in an attempt to assess, evaluate, advise, or make any decision regarding the condition of a member or determine when a member needs to be seen by a licensed medical professional.

Note: Clinical advice may only be provided by appropriately qualified, licensed health professionals, acting within the scope of their licensure, which includes physicians, physiciaants, nurse practitioners and registered nurses.

p.94

2021 / Provider Manual

Nurse Advice Line

VHP members have access to a 24-hours-a-day, seven-days-a-week, 365-days-a-year Nurse Advice Line. The Nurse Advice Line is available at:

Commercial Employer Group: 1.866.682.9492 Covered California and Individual & Family Plan: 1.855.348.9119

Timely Access Monitoring

VHP regularly audits and monitors on an on-going basis, appointment and access standards per applicable rules, regulations, contracts, and guidance. All providers are responsible for responding to any appointment and/or access deficiencies identified by VHP’s review methods, including the following: • Appointment availability survey • After-hours survey • Provider satisfaction survey • Access to care study • Provider demographic survey

p.95

2021 / Provider Manual

CH 13: Claims & Billing Submission

This Chapter Includes:

1. Claims Processing 2. Introduction to Claims

3. Timely Filing 4. Preparing Complete and Accurate Claims 5. Additional Considerations to Ensure Complete & Accurate

Claims and Claims Payment

6. Corrected Claims

7. For Electronic Claims (EDI) 8. For Paper Claims 9. Resubmission Codes

10.Claim and Encounter Submissions

11. Electronic Submission of Claims and Encounters

12.EDI Flow Description 13.UHIN

14.Paper Claim Form Requirements

Alert

Alert draws attention to critical information that has changed this year.

Contact

Contact information on who to contact for assistance.

Book Table of Contents

Click the purple VHP circle logo, located at the bottom left corner, to return to the main TOC.

p.96

2021 / Provider Manual