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Appointment Availability Standards

Appointment Availability

Did you know that Health Plans frequently call to check that your office is complying with appointment availability agreements? As a reminder, as a contracted provider, you have agreed to maintain the following availability standards:
Emergency
Care

Requires immediate face-to-face medical attention

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Urgent
Care

Requires timely face-to face medical attention within 24 hours

Non-Urgent
Care

Requires face-to-face medical attention within 48 to 72 hours

Primary
Care

Requires a face-to-face visit within 4 weeks

Medical care for a condition that, without immediate treatment, could result in:

Placing the member’s life or general health in severe jeopardy

Causing severe impairment in one or more bodily function(s)

Causing severe dysfunction of one or more body organ(s) or parts

Examples of emergency conditions include:

Seizure

Stab/gunshot wound

Diabetic coma

Cardiac arrest

Meningitis

Obvious fracture

Download Appointment Reminder Standards (PDF)

NOTE: If a practitioner is not available, the member should call 911.

 

Medical care given for a condition that, without timely treatment, could result in:

Deteriorating into an emergency

Causing prolonged impairment of bodily functions

Developing a chronic illness

Examples of urgent conditions include:

Abdominal pain of unknown cause

Unremitting new symptoms of dizziness

Suspected fracture

Download Appointment Reminder Standards (PDF)

NOTE: If a practitioner is not available, the member should call 911.

 

Medical care given for a condition that:

Is not emergent or urgent in nature

A delay of several hours would NOT increase the likelihood of an adverse outcome

Examples of non-urgent sick visit include:

Cold symptoms

Sore throat

Nasal congestion

Download Appointment Reminder Standards (PDF)

NOTE: If a practitioner is not available, the member should call 911.

 

Medical care given to diagnose and treat conditions to prevent deterioration:

Minimize/reduce risk of development of chronic illness

Minimize the need for complex treatments

Help prevent health problems before symptoms appear

Examples of routine primary care visits include:

Vaccines

Breast, cervical and colorectal cancer screenings

Blood pressure, diabetes and cholesterol tests

Download Appointment Reminder Standards (PDF)

NOTE: If a practitioner is not available, the member should call 911.