Policy/Procedure Number: MPQP1023 (previously QP100123) / Lead Department: Health Services
Policy/Procedure Title: Access Standards and Monitoring / ☒External Policy
☐ Internal Policy
Original Date: 02/19/2003 / Next Review Date: 08/08/2019
Last Review Date: 08/08/2018
Applies to: / ☒ Medi-Cal / ☐ Employees
Policy/Procedure Number: MPQP1023 (previously QP100123) / Lead Department: Health Services
Policy/Procedure Title:Access Standards and Monitoring / ☒External Policy
☐Internal Policy
Original Date: 02/19/2003 / Next Review Date:08/08/2019
Last Review Date:08/08/2018
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: Robert Moore, MD, MPH, MBA / Approval Date:08/08/2018
  1. RELATED POLICIES: MCLP7002 - Cultural & Linguistics Services
  1. IMPACTED DEPTS:
  2. Member Services
  3. Provider Relations
  4. Quality Improvement
  5. Analytics
  6. Health Education
  7. Compliance
  1. DEFINITIONS:
  2. High-Impact Specialist: Partnership HealthPlan of California (PHC) shall annually identify high-impact specialists by a) identifying practitioner types who treat conditions that have high mortality and morbidity rates and/or b) identifying practitioner types where treatment requires significant resources. PHC will include oncology/hematology as a high impact specialty type every year.
  3. High-Volume Behavioral Healthcare Practitioner: PHC shall identify high volume behavioral healthcare practitioner typesby assessing the number of unique members seen by a given practitioner type within a calendar year. PHC annually selects the top 4 practitioner types with the largest numbers of unique members seen.
  4. High-Volume Specialist (Non-Hospital Specialist): PHC shall identify high-volume specialists by using available claim and encounter data to identify the number of unique members seen by a given specialty type within a calendar year. PHC will select the top 6 specialty types with the largest numbers of unique members seen. PHC will include obstetrics/gynecology as a high-volume specialty type every year.
  5. Rural Counties: Counties with a population density of <50 people per square mile (according to current DHCS standards), includes Del Norte, Humboldt, Lassen, Mendocino, Modoc, Shasta, Siskiyou, Trinity counties.
  6. Suburban or Small Counties: Counties with a population density of 51 to 200 people per square mile (according to current DHCS standards), includes Lake, Napa and Yolo counties.
  7. Urban or Medium Counties: Counties with a population density of 201 to 600 people per square mile (according to current DHCS standards), includes Marin, Solano and Sonoma counties.
  8. Triage or Screening: The assessment of a member’s health concerns and symptoms via communication, with a physician, registered nurse, or other qualified health professional acting within his or her scope of practice and who is trained to screen or triage a member who may need care, for the purpose of determining the urgency of the member’s need for care.
  9. Triage or Screening Wait Time: The time waiting to speak by telephone with a physician, registered nurse, or other qualified health professional acting within his or her scope of practice and who is trained to screen or triage a member who may need care.
  10. Urgent Care: Health care for a condition which requires prompt attention.
  1. ATTACHMENTS:
  2. N/A
  1. PURPOSE:
  1. POLICY / PROCEDURE:

Partnership HealthPlanof California is committed to ensuring that its members have the availability of and accessibility to providers to meet their health care needs. PHC has established standards for the numbers and types of clinicians and facilities, as well as for their geographic distribution, appointment accessibility and office and telephone availability. PHC monitors provider availability and accessibility on an annual basis.

  1. Availability of Practitioners

PHC maintains an adequate network of primary care, behavioral healthcare and specialty care practitioners and monitors how effectively this network meets the needs and preferences of our members.

  1. PHC maintains an overall ratio of total network physicians to members of 1 physician to every 1,200 members (DHCS standard).
  2. Cultural Needs and Preferences:
  3. Cultural and Linguistic Services shall be provided to members in accordance with PHC policy MCLP7002.
  4. PHC assesses the cultural, ethnic, racial and linguistic needs of its members every three years and adjusts the availability of practitioners within the network, if necessary (NCQA requirement).
  5. Practitioners Providing Primary Care: To evaluate the availability of practitioners who provide primary care services, including general medicine or family medicine, internal medicine and pediatrics, PHC:
  6. Establishes measureable standards for the number of each type of practitioner providing primary care.

NUMBER OF PRACTITIONERS, PRIMARY CARE [1]
Practitioner Type / Measure: Ratio / Standard/Performance Goal
Primary Care Provider overall / Primary care provider to member (adult and children) / 1:≤ 2,000 (DHCS standard)
Family Practice/General Practice / Family or General practice practitioner to member (adult and children) / 1:≤ 2,000
Pediatrics / Pediatricians to members (children) / 1:≤ 2,000
Internist / Internists to members (adult) / 1:≤ 2,000
  1. Establishes measurable standards for the geographic distribution of each type of practitioner providing primary care.

GEOGRAPHIC DISTRIBUTION OF PRACTITIONERS, PRIMARY CARE[2]
Practitioner Type / Standard: Geographic Distribution / Performance Goal
Primary Care Physician overall / 1 within 10 miles or 30 minutes from the member’s residence (DHCS standard) / ≥ 95%
Family Medicine /General Practitioner / 1 within 30 miles or 60 minutes from the member’s residence / ≥ 95%
Pediatrics / 1 within 30 miles or 60 minutes from the member’s residence / ≥ 95%
Internist / 1 within 30 miles or 60 minutes from the member’s residence / ≥ 95%
Obstetrics/Gynecology / 1 within 10 miles or 30 minutes from the member’s residence (DHCS standard) / ≥ 95%
Geographic Distribution - Alternative Access Standards: Primary Care Provider [3]
Practitioner Type / County / Zip Code / Alternative Geographic Access Standard
PCP - Adult and Pediatric / Lassen / 96109 / 1 within 45 miles or 60 minutes from member’s residence
PCP - Adult and Pediatric / 96113, 96119, 96121, 96123, 96132 / 1 within 30 miles or 60 minutes of residence
PCP - Adult and Pediatric / Modoc / 96015, 96108, 96112 / 1 within 30 miles or 60 minutes of residence
PCP - Adult / Siskiyou / 96031 / 1 within 30 miles or 60 minutes of residence
PCP - Pediatric / 96023, 96031, 96044, 96058, 96064 / 1 within 30 miles or 60 minutes of residence
PCP - Pediatric and Adult / Trinity / 96091 / 1 within 30 miles or 60 minutes of residence
  1. Annually analyzes performance against the standards for the number of each type of practitioner providing primary care (NCQA requirement).
  2. Annually analyzes performance against the standards for the geographic distribution of each type of practitioner providing primary care (NCQA requirement).
  1. Practitioners Providing Specialty Care: To evaluate the availability of specialists in PHC’s delivery system, PHC:
  2. Identifies high-volume specialists (NCQA requirement) by assessing the number of unique members seen by a given specialty type within a calendar year. PHC annually selects the top 6 specialty types with the largest numbers of unique members seen. PHC’s current high-volume specialty types are:

1)Obstetrics/gynecology

2)Cardiology

3)Orthopedics

4)General Surgery

5)Ophthalmology

6)Dermatology

  1. Identifies high-impact specialists (NCQA requirement) by identifying practitioner types who treat conditions that have high mortality and morbidity rates and/or identifying practitioner types where treatment requires significant resources. PHC’s current high-impact specialty type is:

1)Oncology/Hematology

  1. Monitors geographic availability for additional specialty types defined by DHCS as “Core Specialists.”

DHCS ADULT AND PEDIATRIC CORE SPECIALISTS
Cardiology/Interventional Cardiology* / Gastroenterology / Nephrology / Orthopedic Surgery*
Dermatology* / General Surgery* / Neurology / Physical Medicine and Rehabilitation
Endocrinology / Oncology/ Hematology ** / Psychiatry
ENT/Otolaryngology / HIV/AIDS Specialists/Infectious Diseases / Ophthalmology* / Pulmonology
*High-volume specialty type; **High-impact specialty type
  1. Establishes the following measureable standards for the number of each type of high-volume specialist. (Note: PHC does not establish ratio standards for high-impact specialists, or DHCS Core specialty types not identified as high volume.)

NUMBER OF PRACTITIONERS, HIGH-VOLUME SPECIALISTS[4]
Practitioner Type / Measure: Ratio / Standard/Performance Goal (Ratio of specialists to members)
Obstetrics/Gynecology / OB-GYN to Member / 1: ≤ 2,000
Cardiology / Cardiologist to Member / 1: ≤2,000
Orthopedics / Orthopedic Surgeon to Member / 1: ≤ 3,000
General Surgery / General Surgery to Member / 1: ≤ 2,000
Ophthalmology / Ophthalmology to Member / 1: ≤ 3,000
Dermatology / Dermatology to Member / 1: ≤ 5,000
  1. Establishes measureable standards for the geographic distribution of each type of specialist (high-volume, high-impact, and DHCS Core).

GEOGRAPHIC DISTRIBUTION OF PRACTITIONERS, SPECIALTY CARE[5]
Practitioner Type / Standard: Geographic Distribution / Performance Goal
  • Cardiology*+
  • Dermatology*+
  • Endocrinology+
  • ENT/Otolaryngology+
  • Gastroenterology+
  • General Surgery*+
  • HIV/AIDS Specialists/Infectious Diseases+
  • Nephrology+
  • Neurology+
  • Obstetrics/Gynecology (as specialist)*
  • Ophthalmology*+
  • Orthopedics*+
  • Physical Medicine and Rehabilitation+
  • Pulmonology+
/
  • Urban/Medium: One within 30 miles or 60 minutes from member’s residence
  • Suburban/Small: One within 45 miles or 75 minutes from member’s residence
  • Rural: One within 60 miles or 90 minutes from member’s residence
(DHCS Standard) / ≥ 90%
Oncology/Hematology **+ / ≥ 80%
*High-volume specialty type; **High-impact specialty type; +DHCS Core Specialists
Geographic Distribution – Alternative Access Standards: Specialty Care Providers - Adult/Pediatric [6]
Specialty Type / County / Zip Code(s) / Alternative Geographic Access Standard
Physical Medicine Rehab / Humboldt / 95501, 95502, 95528, 95536, 95540, 95542, 95545, 95547, 95554, 95558, 95560, 95562, 95565, 95569, 95571, 95587, 95589 / One within 90 miles or 120 minutes from member’s residence
Hematology / Lassen / 96109 / One within 90 miles or 120 minutes from member’s residence
96113, 96117, 96130, 96132, 96136 / One within 120 miles or 180 minutes from member’s residence
96119, 96123 / One within 165 miles or 270 minutes from member’s residence
Oncology / 96109, 96113, 96117, 96119, 96130, 96132, 96136 / One within 90 miles or 120 minutes from member’s residence
96123 / One within 120 miles or 180 minutes from member’s residence
Ophthalmology / 96109, 96113, 96114, 96117, 96119, 96121, 96127, 96128, 96130, 96132, 96136 / One within 90 miles or 120 minutes from member’s residence
96123 / One within 120 miles or 180 minutes from member’s residence
Physical Medicine Rehab / 96109, 96113, 96117, 96119, 96128, 96130, 96132, 96136 / One within 90 miles or 120 minutes from member’s residence
96123 / One within 120 miles or 180 minutes from member’s residence
Physical Medicine Rehab / Mendocino / 95417, 95437, 95454, 95488, 95585, 95587, 95589 / One within 90 miles or 120 minutes from member’s residence
Hematology / Modoc / 96006 / One within 120 miles or 180 minutes from member’s residence
96015, 96054, 96101, 96104, 96108, 96110, 96112, 96115, 96116, 96134 / One within 165 miles and 270 minutes from members residence
Oncology / 96006, 96015, 96054, 96134 / One within 90 miles or 120 minutes from member’s residence
96101, 96104, 96108, 96110, 96112, 96115, 96116 / One within 120 miles or 180 minutes from member’s residence
Ophthalmology / 96006, 96015, 96054 / One within 90 miles or 120 minutes from member’s residence
96101, 96104, 96108, 96110, 96112, 96115, 96116 / One within 120 miles or 180 minutes from member’s residence
Physical Medicine Rehab / 96006, 96015, 96054, 96134 / One within 90 miles or 120 minutes from member’s residence
96101, 96104, 96108, 96110, 96112, 96115, 96116 / One within 120 miles or 180 minutes from member’s residence
Hematology / Siskiyou / 96023, 96044, 96058, 96064, 96097, 96134 / One within 165 miles and 270 minutes from members residence
Oncology / 96023, 96044, 96058, 96064,96097, 96134 / One within 90 miles or 120 minutes from member’s residence
Physical Medicine Rehab / 96023, 96044, 96058, 96064, 96097, 96134 / One within 90 miles or 120 minutes from member’s residence
  1. Analyzes performance against the established specialty care availability standards at least annually (NCQA requirement).
  1. Practitioners Providing Behavioral Healthcare: To evaluate the availability of high-volume behavioral healthcare practitioners in its delivery system, PHC:
  2. Identifies high volume behavioral healthcare practitioners (NCQA requirement) by assessing the number of unique members seen by a given practitioner type within a calendar year. PHC annually selects the top 4 practitioner types with the largest numbers of unique members seen. PHC’s current high-volume practitioner types are:

1)Psychiatrist

2)Clinical psychologist

3)Licensed clinical social worker

4)Marriage and family counselor

  1. Establishes measurable standards for the number of each type of high-volume behavioral healthcare practitioner.

NUMBER OF PRACTITIONERS, BEHAVIORAL HEALTHCARE[7]
Practitioner Type / Measure: Ratio / Standard/
Performance Goal
Psychiatrist / Psychiatrist to members / 1: ≤50,000
Clinical psychologist / Clinical psychologist to member / 1: ≤30,000
Licensed clinical social / Licensed clinical social worker to member / 1: ≤10,000
Marriage and family counselor / Marriage and family counselors to members / 1: ≤10,000
  1. Establishes measureable standards for the geographic distribution of each type of high-volume behavioral healthcare practitioner.

GEOGRAPHIC DISTRIBUTION OF PRACTITIONERS, BEHAVIORAL HEALTHCARE[8]
Practitioner Type / Standard: Geographic Distance / Performance Goal
  • Psychiatrist+
  • Clinical psychologist
  • Licensed clinical social
  • Marriage and family counselor
+DHCS Core Specialist /
  • Urban/Medium: One within 30 miles or 60 minutes from member’s residence
  • Suburban/Small: One within 45 miles or 75 minutes from member’s residence
  • Rural: One within 60 miles or 90 minutes from member’s residence
(DHCS Standard) / ≥ 90%
  1. Analyzes performance against the established behavioral healthcare availability standards annually (NCQA requirement).
  1. Pharmacy: To evaluate the availability of pharmacy services, PHC establishes measureable standards for the geographic distribution of pharmacies.

GEOGRAPHIC DISTRIBUTION OF PHARMACIES
Practitioner Type / Standard: Geographic Distance
Pharmacy / One within 10 miles or 30 minutes from member’s residence (DHCS standard)
  1. Hospitals: To evaluate the availability of hospital services, PHC establishes measureable standards for the geographic distribution of hospitals.

GEOGRAPHIC DISTRIBUTION OF HOSPITALS
Practitioner Type / Standard: Geographic Distance
Hospital / One within 15 miles or 30 minutes from member’s residence (DHCS standard)
Alternative Geographic Distribution Access Standards: Hospital
County / Zip Code(s) / Alternative Access Standard
Del Norte / 95543 / One within 30 miles or 60 minutes from member’s residence
Humboldt / 95526, 95546, 96046, 95550, 95555, 95556, 95558, 95563, 95573 / One within 30 miles or 60 minutes from member’s residence
Lassen / 96109 / One within 45 miles or 75 minutes from member’s residence
96113, 96119 96121, 96123, 96132, 96137 / One within 30 miles or 60 minutes from member’s residence
Mendocino / 95417, 95428, 95432, 95445, 95454, 95459, 95468 / One within 30 miles or 60 minutes from member’s residence
Modoc / 96006, 96015, 96112, 96054 / One within 30 miles or 60 minutes from member’s residence
96108, 96134 / One within 45 miles or 75 minutes from member’s residence
Shasta / 96008, 96047,96051, 96059, 96065, 96069, 96076, 96084, 96088, 96096 / One within 30 miles or 60 minutes from member’s residence
Siskiyou / 96014, 96023, 96027, 96039, 96044, 96050, 96057, 96058, 96064, 96086, / One within 30 miles or 60 minutes from member’s residence
96031, 95568, 96134 / One within 45 miles or 75 minutes from member’s residence
Sonoma / 95412, 95480, 95497 / One within 30 miles or 60 minutes from member’s residence
Trinity / 95526, 95527, 96041, 96046, 95552, 95563, 96091, 95595 / One within 30 miles or 60 minutes from member’s residence
96052 / One within 35 miles or 35 minutes from member’s residence
Yolo / 95606, 95937 / One within 30 miles or 60 minutes from member’s residence
  1. Accessibility of Services

PHC provides and maintains appropriate access to primary care, specialty care and behavioral healthcare services.

1.Access to Primary Care

  1. Regular and Routine Care Appointments:

1)Non-Urgent Primary Care Appointments: These appointments include preventive visits and follow-up visits. Appointments should be provided within 10 business days of request.

2)Prenatal Care Appointments: Pregnant members should be provided an initial prenatal care appointment within 10 business days of request.

3)Newborn Appointments: Infants discharged from hospital in less than 48 hours of life after delivery should be seen within 48 hours of discharge. The follow-up visit can take place in a home or clinic setting as long as the health care professionals examining the infant are competent in newborn assessment and the results of the follow-up visit are reported to the infant’s physician or his or her designees on the day of the visit where the PCP is not examining the infant. (PHC standard)

  1. Urgent Care Appointments

1) Appointments that do not require prior authorization- within 48 hours of a request.

ACCESSIBILITY TO PRIMARY CARE PRACTITIONERS[9]
Timely Access Standard / Performance Goal
Non-Urgent Care primary care appointments within 10 business days of request (DHCS standard) / ≥ 90%
Prenatal Care appointments within 10 business days of request(DHCS standard) / ≥ 90%
Newborn appointments within 48 hours of discharge (PHC standard) / ≥ 90%
Urgent Care appointments without prior authorization within 48 hours of request (DHCS standard) / ≥ 90%
  1. Access to Specialty Care
  2. Appointments for non-urgent specialty care shall be provided within 15 business days of member’s referral. (This standard applies to all Specialty type referenced in section A.4.e.)

ACCESSIBILITY TO SPECIALTY CARE PRACTITIONERS[10]
Timely Access Standard / Performance Goal
Non-Urgent Care specialty appointments within 15 business days of request (DHCS standard) / ≥ 80%
  1. Access to Behavioral Healthcare
  2. Routine office visits (initial and follow-up care) within 10 business days of member’s request (DHCS and NCQA standard).
  3. Urgent and Emergency care: Coverage for moderate to severe behavioral health is a carved out benefit and members are referred out to county emergency services. Members who contact PHC or contact our delegated providers, Beacon Health Options and Kaiser Permanente, with a psychiatric emergency are immediately redirected to county mental health providers for appropriate psychiatric crises intervention and follow-up care. Both PHC and our delegated providers have policies and protocols in place to ensure the member’s safety and well-being during such redirection.

ACCESSIBILITY TO BEHAVIORAL HEALTHCARE
Timely Access Standard / Performance Goal
Routine office visits (initial and follow-up care) within 10 business days of request (DHCS standard) / ≥ 80%
  1. Access to Emergency Care
  2. Emergency treatment must be available immediately to all members 24 hours a day. During hours when PCP offices are closed, members should be directed to an after-hours or emergency care location depending on the nature of the problem.
  1. Access to Pharmacy
  2. Request for prior authorization made via telecommunications: within 24 hours (DHCS requirement).
  3. Dispensing of at least a 72 hour supply of a covered outpatient drug in an emergency situation (DHCS requirement).
  4. Primary Care Practitioner and Specialty CareOffice Hours and Telephone Access Standards

1.Regular Business Hours

  1. PCP practices must be open and staffed by a clinician(s) who is available to members for a minimum of 20 hours per week. PCPs with multiple sites less than ten (10) miles apart that see members at either site may combine open hours to meet the requirements.
  2. Office hours and an emergency 24-hour number must be displayed in a clearly visible area, window, or door.
  3. Hours of operation must be adequate and convenient for members to schedule appointments and should not in any way discriminate against Partnership HealthPlan members.
  4. When calling the providers office:

1)Phone calls are answered with 5 rings

2)Maximum time on hold is 5 minutes

3)Phone messages left for provider during regular business hours should be responded to within 30 minutes of the call.