Emergency
Medical situations in which a member would reasonably believe his/her life to be in danger, or that permanent disability might result if the condition is not treated Immediate access, 24 hours a day, 7 days a week
• Loss of consciousness
• Seizures
• Chest pain
• Severe bleeding
• Trauma
Urgent
Medical conditions that could result in serious injury or disability if medical attention is not received 30 hours or less
• Severe or acute pain
• High fever in relation to age and condition Routine Primary Care Problems that could develop if untreated but do not substantially restrict a member’s normal activity 5 to 14 days
• Backache
• Suspicious mole
Preventive Care
Routine exams 6 weeks or less
• Routine physical
• Well baby exam
• Annual Pap smear
Additional Availability Standards
• Network physicians are responsible for assuring access to services 24 hours a day, 365 days a year other than in an emergency room for non-emergent conditions. This includes arrangements to assure patient awareness and access after hours to another participating physician.
• All network providers must offer services during normal working hours, typically between 9 a.m. and 5 p.m.
• Average office waiting times should be no more than 30 minutes for patients who arrive on time for a scheduled appointment.
• The physician’s office should return a patient’s call within four to six hours for an urgent/acute medical question and within 24 hours for a non-urgent issue.
Acute Care Hospital Availability Standards
• Acute care hospitals are responsible for assuring access to services 24 hours a day, 365 days a year.
• All contracted hospitals must maintain emergency room or urgent care services on a 24-hour basis and must offer outpatient services during regular business hours, if applicable.
Medical situations in which a member would reasonably believe his/her life to be in danger, or that permanent disability might result if the condition is not treated Immediate access, 24 hours a day, 7 days a week
• Loss of consciousness
• Seizures
• Chest pain
• Severe bleeding
• Trauma
Urgent
Medical conditions that could result in serious injury or disability if medical attention is not received 30 hours or less
• Severe or acute pain
• High fever in relation to age and condition Routine Primary Care Problems that could develop if untreated but do not substantially restrict a member’s normal activity 5 to 14 days
• Backache
• Suspicious mole
Preventive Care
Routine exams 6 weeks or less
• Routine physical
• Well baby exam
• Annual Pap smear
Additional Availability Standards
• Network physicians are responsible for assuring access to services 24 hours a day, 365 days a year other than in an emergency room for non-emergent conditions. This includes arrangements to assure patient awareness and access after hours to another participating physician.
• All network providers must offer services during normal working hours, typically between 9 a.m. and 5 p.m.
• Average office waiting times should be no more than 30 minutes for patients who arrive on time for a scheduled appointment.
• The physician’s office should return a patient’s call within four to six hours for an urgent/acute medical question and within 24 hours for a non-urgent issue.
Acute Care Hospital Availability Standards
• Acute care hospitals are responsible for assuring access to services 24 hours a day, 365 days a year.
• All contracted hospitals must maintain emergency room or urgent care services on a 24-hour basis and must offer outpatient services during regular business hours, if applicable.
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