Timeliness of Access to Care. In accordance with 42 CFR §438.206(c)(1)(i), the MCO must have standards for timeliness of access to care and enrollee services that take into account the urgency of the need for services and that meet or exceed such standards as may be established by BMS. In accordance with 42 CRF §438.206(c), the MCO must also regularly monitor its provider network’s compliance with these standards, and take corrective action as necessary. Current BMS standards for timeliness state that: Emergency cases must be seen immediately or referred to an emergency facility; Urgent cases must be seen within forty-eight (48) hours; Routine cases other than clinical preventive services, must be seen within twenty-one
Timeliness of Access to Care. In accordance with 42 CFR §438.206(c)(1)(i), the MCO must have standards for timeliness of access to care and enrollee services that take into account the urgency of the need for services and that meet or exceed such standards as may be established by BMS. In accordance with 42 CRF §438.206(c), the MCO must also regularly monitor its provider network’s compliance with these standards, and take corrective action as necessary. The MCO must have protocols for identifying enrollees experiencing barriers with access to care and who cannot be reached by the MCO, including use of data to support improved access and overall outcomes. Methods may include, but not be limited to, review of focus group and survey findings, analysis of utilization, complaints and grievances, PCP change requests, out-of-network referrals and ER usage. Current BMS standards for timeliness state that: • Emergency cases must be seen immediately or referred to an emergency facility; • Urgent cases must be seen within forty-eight (48) hours; • Routine cases other than clinical preventive services, must be seen within twenty-one
Timeliness of Access to Care. The MCO must have standards for timeliness of access to care and enrollee services that take into account the urgency of the need for services and that meet or exceed such standards as may be established by BMS. The MCO must also regularly monitor its provider network’s compliance with these standards, and take corrective action as necessary. Current BMS standards for timeliness state that: • Emergency cases must be seen immediately or referred to an emergency facility; • Urgent cases must be seen within forty-eight (48) hours; • Routine cases other than clinical preventive services, must be seen within twenty-one
Timeliness of Access to Care. The MCO must have standards for timeliness of access to care and enrollee services that take into account the urgency of the need for services and that meet or exceed such standards as may be established by DHHR. The MCO must also regularly monitor its provider network’s compliance with these standards, and take corrective action as necessary. Current DHHR standards for timeliness state that: • Emergency cases must be seen immediately or referred to an emergency facility; • Urgent cases must be seen within forty-eight (48) hours; • Routine cases other than clinical preventive services, must be seen within twenty- one (21) calendar days (exceptions are permitted at specific times when PCP capacity is temporarily limited); • EPSDT services must be scheduled in accordance to EPSDT guidelines and the EPSDT Periodicity Schedule; • An initial prenatal care visit must be scheduled within fourteen (14) calendar days of the date on which the woman is found to be pregnant; and • MCOs should encourage enrollees with Supplemental Security Income (SSI) to schedule an appointment with a PCP or specialist who manages the enrollee’s care within forty-five (45) calendar days of initial enrollment. If requested by the enrollee or provider, the MCO should schedule or facilitate an appointment with the enrollee’s PCP.
