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Provider Manual

Access Standards

Last Updated on September 24, 2018

All members have the right to receive timely access to medically necessary health care services. To facilitate this, the Quality Improvement (QI) Committee approves member access standards and annually evaluates Security Health Plan’s affiliated providers’ compliance with these standards.

Standards

An expectation of in-office wait time for appointment is no longer than 20 minutes. Members with life-threatening emergencies will have immediate access to care, 24 hours a day, every day of the year without prior authorization from Security Health Plan. Members may receive such emergency care from either affiliated or nonaffiliated providers at hospitals that are within or outside of Security Health Plan’s service area. All hospitals in Security Health Plan’s service area offer emergency room services 24 hours a day.

Primary care provider standards

Time frames for member requested appointments are:

Service
Appointment timing
 Life-threatening emergencies
Immediate access
 Urgent need
Within 24 hours (or as soon as the member believes necessary)
 Routine preventive exam (adult or child)
Within 30 days for BadgerCare Plus within 60 calendar days
 Routine non-urgent/problem focus
Within 14 calendar days

Behavioral health care providers:

Members have direct access to affiliated behavioral health providers. Time frames for member requested appointments are:

Service
Appointment timing
Life-threatening emergencies
Immediate access
Non life-threatening emergency
Within 6 hours
Urgent needs
Within 48 hours
Routine office visit
Within 7 days

BadgerCare Plus prenatal care

Provider must provide medically necessary high-risk prenatal care within two weeks of the member's request for an appointment, or within three weeks if the request is for a specific provider, who is accepting new patients.

After hours coverage for providers

Physicians who accept “on-call” responsibility for network primary care providers and specialty care physicians are subject to the same standards for access and availability.

Primary care providers and behavioral health providers must have a system in place for ensuring after hours accessibility for their patients, and for informing their patients about how to access after hours care. After-hours patient telephone calls should be returned within 1 hour from the time placed by the patient.

All providers will be required to provide patients with an emergency telephone number for use after regular office hours. Telephone numbers should also include a description of 24-hour/day access to health care.

Provider must be consistent and can not discriminate towards BadgerCare members.