Accessibility Expectations: Ensuring Timely Access to Care

As a participating Highmark provider, you must adhere to specific in-person and telehealth appointment scheduling standards, including:

• Urgent care: Immediate appointment.
• Non-urgent care: Within 48-72 hours.
• Initial routine physical/preventative care (PCP/OB-GYN): Within three weeks.
• Routine care, subsequent routine: Within seven days.
• Initial behavioral health assessment or subsequent care (outpatient or office): Within seven days.
• Non-life-threatening behavioral health (BH): Within six hours and direct members to a behavioral health crisis unit, 988 suicide and crisis lifeline, and the nearest emergency room (ER).
• Follow-up after hospital discharge: PCP/Specialist within five days, BH in two days.
• After-hours care: Requires acceptable 24/7 phone coverage weekly.
• Facility services: Must be available 24/7 when medically appropriate. Verify physician qualifications if services are provided on behalf of the facility.
• Appointment wait time: Practitioners are expected to see the member within 15 minutes from their scheduled appointment.
• Routine visits scheduled within one hour (PCP/OB-GYN): Five visits per hour.

These appointment expectations are set forth by the health plan, at the direction of the state and federal regulatory bodies, including, but not limited to:

• Centers for Medicare and Medicaid Services (CMS)
• National Committee for Quality Assurance (NCQA)

No Preconditions When Scheduling an Appointment

Conditions must not be imposed on members when requesting an appointment.

• Members cannot be asked to complete forms, provide identification documentation, or share medical records prior to the provider scheduling the appointment.
• An appointment must always be scheduled at the time the member calls the practice and must be scheduled in compliance with the PCP and Medical Specialist, and BH accessibility expectations referenced below.
• An appointment must not be contingent on the member's ability or inability to complete paperwork prior to the telehealth or in-person office visit.