Network Availability Standards Policy and Procedure

Policy/Procedure Number: MP PR 201A / Lead Department: Provider Relations /
Policy/Procedure Title: Network Availability Standards Policy and Procedure / ☒External Policy
☐Internal Policy /
Original Date: 06/21/2006 / Next Review Date: 11/21/2018
Last Review Date: 11/15/2017 /
Applies to: / ☒ Medi-Cal / ☐ Employees /
Policy/Procedure Number: MP PR 201A / Lead Department: Provider Relations /
Policy/Procedure Title: Network Availability Standards / External Policy
Internal Policy /
Original Date: 06/21/2006 / Next Review Date: 11/21/2018
Last Review Date: 11/15/2017 /
Applies to: / Medi-Cal / Employees /
Reviewing Entities: / IQI / P & T / QUAC /
OPerations / Executive / Compliance / Department /
Approving Entities: / BOARD / COMPLIANCE / FINANCE / PAC
CEO / COO / Credentialing / DEPT. DIRECTOR/OFFICER
Approval Signature: Jeffrey Gaborko, MD / Approval Date: 11/15/2017

I.  RELATED POLICIES:

N/A

II.  IMPACTED DEPTS:

A.  Provider Relations

III.  DEFINITIONS:

N/A

IV.  ATTACHMENTS:

A.  N/A

V.  PURPOSE:

To ensure geographic access and availability to Primary Care, Specialty Care and Hospital Services for Partnership HealthPlan of California (PHC) Members.

VI.  POLICY / PROCEDURE:

A.  PHC monitors PCP, Specialty, and Hospital availability based on established standards.

1.  PHC is responsible for monitoring PCP access and availability. Primary Care physicians include General and Family Practitioners, Internists, Gerontologists, Obstetrician-Gynecologists and Pediatricians. The PCP availability standard is defined below as:

2.  One (1) PCP office site located within 30 minutes or 10 miles of member's residence.

B.  PCP Availability

1.  PHC conducts an annual PCP GeoAccess® analysis based on PCP site zip code and zip code of member to verify PCP office site locations meet availability standards.

C.  Number of PCPs to Members

1.  PHC annually monitors the total number of PCPs to Members. DHCS standard is 1 PCP to 2000 members or 1 non-Physician medical practitioner to 1000 members. PHC has established number of PCP sites Available, OPEN to new patients per community and number of members residing in community. Refer to policy MP PR #204, Goals Primary Care Services Availability.

a.  Specialty Availability Standard

1)  One (1) High Volume and/or Key Specialty Physician within 30 miles of member’s residence.

D.  Specialty Availability

1.  Specialty physician availability is monitored by identifying the highest volume specialty providers through claims data. A GeoAccess® report is generated based on zip code of provider and zip code of member.

2.  Total Physician Full Time Equivalent

a.  Per DHCS standard. PHC shall ensure overall Physician ratio is 1 Physician to 1200 members. PHC reviews physician network to ensure standard is met. The PCP to member ratio and overall specialty physician to member ratio is reported as part of the annual assessment of network access and availability.

3.  Hospital Availability Standard

a.  Hospital located within 30 miles of member’s residence.

4.  Hospital Availability

a.  Hospitals availability is monitored by identifying through GeoAccess® reports based on hospital zip code that hospital facility is located within 30 miles of member’s residence.

5.  The Provider Relations Department is responsible for working with the PHC Finance Department to complete the analysis. Once the report has been completed the results will be reviewed by the staff from the Quality Improvement and Provider Relations Departments. The final report may be submitted to the appropriate PHC committees for recommendation and corrective action as necessary.

6.  On an annual basis PHC conducts a survey to monitor the cultural and linguistic capabilities of the primary care network. The final report is reviewed by appropriate PHC staff from Health Services, Quality Improvement, Provider Relations, and Members Services. Results and/or corrective action plans may be submitted to the appropriate PHC committees for review and recommendations.

VII.  REFERENCES:

A.  - DHCS

B.  - CMS

VIII.  DISTRIBUTION:

A.  - PHC Provider Manual

IX.  POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE:

Senior Director, Provider Relations

X.  REVISION DATES:

Medi-Cal

06/21/2006, 05/16/07, 07/16/08, 03/18/09, 05/15/09, 07/21/10, 07/20/11, 08/15/12, 08/14/13, 09/10/14, 11/18/2015, 11/16/2016, 11/15/2017

PREVIOUSLY APPLIED TO:

PartnershipAdvantage:

MP PR #201A - 06/2006 to 01/01/2015

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