Accessibility to Care Standards

Highmark Wholecare’s Medicaid and Medicare Accessibility Standards:

• Medicaid Appointment Access Standards
• Medicare Appointment Access Standards
• Medicare Behavioral Health Access Standards Detail
  

Highmark Wholecare has contracted with Press Ganey, a National Committee for Quality Assurance (NCQA) certified vendor, to conduct annual audits to assess our provider network’s ability to provide Highmark Wholecare members with timely access to care.

The audit addresses:

• Appointment availability based on Highmark Wholecare standards
• Access to care 24 hours a day, 7 days a week
• Wait time in the waiting room
• Missed appointment protocol

The audit results are utilized to identify plan strengths and barriers to care and provides Highmark Wholecare with the opportunity to develop initiatives to improve access.

Accessibility Audit

The Accessibility audit is conducted annually, typically in the 2nd Quarter of the year.

• Press Ganey will contact a random sample of our provider network by phone to complete the audit. Call-center agents will ask series of questions to determine compliance with Highmark Wholecare Accessibility Standards.
• The call-center agent will request that the office appointment schedule be reviewed (real-time) to obtain a specific date and time of the office’s next available appointment.
• Identification of office protocol or instructions provided to members by provider offices may also be included as part of the audit.

Important Audit Information

• Providers are contractually obligated to participate in the audit.
• Highmark Wholecare will announce the upcoming annual audit via fax blast and provider newsletter
• Scheduling staff should be educated on the standards and aware of the audit time frame
• The audit is conducted telephonically and will take 5 minutes to complete
• Provider offices that are non-compliant with one or more standards will receive a report card identifying each non-compliant standard along with required actions

What You Can do to Prepare for the Audit

• Key office staff that schedule member appointments should review Highmark Wholecare’s Practitioner Accessibility Standards.

Important: Education of staff responding to the accessibility audit questions is a contributing factor to compliance with the standards.

• Complete a Practice Self-Assessment to determine if your practice meets Highmark Wholecare’s Access to Care Standards.

Practice Self-Assessment Tool: The tool contains the accessibility standards monitored by Highmark Wholecare for both Medicaid and Medicare, the criteria a practice must meet to be compliant with the standards and identifies questions that may be asked by call-center agents during an Accessibility Audit.

Highmark Wholecare’s Annual Provider Accessibility Audit Process: Annual Provider Accessibility Audit Process

Provider offices that are non-compliant with one or more standards will receive a report card identifying each non-compliant standard along with required actions to mitigate non-compliance.

Non-compliant: One (1) year

Providers that are non-compliant with 1 or more standards based on the results of the annual audit will be:

• Required to submit an action plan within 45 days
• Required to complete staff training within 45 days
• Required to complete a practice self-assessment of compliance within 45 days
• Required to attest to the completion of staff training and practice self-assessment within 45 days

Note: Your completion of the provider access corrective action plan online submission form on the provider website will satisfy all actions listed above.

• Resurveyed in the following years annual audit
  Example of Audit Results Notification Noncompliant 1 Year
  

Non-Compliant: Two (2) consecutive years

Providers that are non-compliant with 1 or more standards for two consecutive years based on the results of the annual audit and the previous year annual audit will be:

• Required to submit an action plan within 45 days
• Required to complete staff training within 45 days
• Required to complete a practice self-assessment of compliance within 45 days
• Required to attest to the completion of staff training and practice self-assessment within 45 days

Note: Your completion of the provider access corrective action plan online submission form on the provider website will satisfy all actions listed above.

• Additional actions may be required.
• Resurveyed in the following years annual audit
  “Example of Audit Results Notification Non-compliant 2 Year”

• Ensure that you have coverage for vacation or an extended absence by another practitioner or you can refer members to another practice or telemedicine provider. Refer to the Medicaid and Medicare Provider Manuals on our provider website for more information regarding telemedicine.
• Share the accessibility standards, Audit questions, and Audit process with key staff that schedule appointments, including central scheduling/call centers. Education of staff responding to the audit questions is a contributing factor to compliance with the standards.

Highmark Wholecare’s Practice Self-Assessment Tool:
Practice Self-Assessment Tool

Frequently Asked Questions (FAQs)

Thank you for choosing to complete your Provider Access Corrective Action Plan (CAP) online. Your practice site should have received a Provider Report Card. This Report Card outlines your Provider Access Audit Results and what standards your site has failed that require a CAP. Please follow the below steps to complete the CAP form.

Click here to see what is needed to complete the online submission form.

Click here to complete the CAP form.

Behavioral Health Provider Access Education Recording - YouTube Video

Behavioral Health Provider Access Education - PDF