Help

Quality Improvement

 

 

Medical Access Standards

· Life-Threatening Medical Problems. Members with life-threatening medical problems will have access to acute medical care with participating or nonparticipating providers 24 hours a day, seven days a week.

· Urgent/Acute Medical Problems. Members with urgent/acute (but not life threatening) medical problems will have access to specialty-appropriate medical services with participating or nonparticipating providers within 24 hours of the request of service.

· Nonurgent/Non-Acute Medical Problems. Members with nonurgent/non-acute medical problems will have access to a specialty-appropriate participating provider within seven calendar days of the request of service.

· Well-Person Care or Chronic Illness Routine Evaluations. Members who need well-person care or chronic illness routine evaluations will have access to specialty-appropriate participating providers and facilities within 30 calendar days of the request for service. The standard shall be within 21 calendar days for well newborns younger than one month of age. This standard does not apply to routine eye refractions or hearing screens.

· Waiting Room Standards. Providers will see the patient within an average of 30 minutes after the patient’s arrival for an office visit.

· Equal Access. Participating providers or their designees (primary care and specialty) will be available for telephone consultation to members in a fashion consistent with the access granted by the provider for their patients who do not have SelectHealth insurance.

· 24-Hour Physician Availability. Providers or their comparable covering designees will be available by telephone for emergent and/or urgent situations 24 hours a day.

Behavioral Health Access Standards

· Life-Threatening Problems. Members with life-threatening behavioral health problems (crisis) will have access to acute medical care with participating or nonparticipating providers 24 hours a day, 365 days of the year. A crisis is defined as persons presenting with acute symptoms of immediate, actual, or potential danger to self, others, or property. Providers should direct members to the Emergency Room (ER) if they are experiencing a behavioral health emergency.  ​

· Non Life-Threatening Problems. Members with non life-threatening emergent behavioral health problems will have access to care within six hours. A non life-threatening emergent behavioral health problem is defined as persons not at risk to harm themselves or others. However, if the problem is left unattended, it would exacerbate into a crisis.

· Urgent Problems. Members with urgent behavioral health problems will have access to care within 48 hours.

· Routine Problems. Members with routine behavioral health problems will have access to care within ten business days.

· Waiting Room Standards. Providers will see the patient within an average of 30 minutes after the patient’s arrival for an office visit.

· Equal Access. Participating providers or their designees will be available for telephone consultation to members in a fashion consistent with the access granted by the provider for their patients who do not have SelectHealth insurance.

· 24-Hour Physician Availability. Providers or their comparable covering designees will be available by telephone for emergent and/or urgent situations 24 hours a day.

Monitoring Patient Access

SelectHealth will monitor member access to care using the following methods:

· Annual Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Survey. The CAHPS Survey will be used to measure compliance with accessibility to the following services:

· Urgent medical health problems.
· Nonurgent regular or routine medical problems.

*CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

· Member Calls. SelectHealth monitors calls to Member Services or the SelectHealth Member Advocates® team regarding access or service problems. Such inquiries or complaints are tracked and reported to the Quality Improvement committee to identify access barriers.

· After-hours access survey.

· Behavioral health failed access reports.

· Appointment wait-time surveys.

· Other methods as appropriate.


​​

© 2020 SelectHealth, All rights reserved.