Appointment availability standards
- What are appointment availability standards?
- How do you as a provider with Texas Children’s Health Plan play a role?
In 2015 Senate Bill 760 passed, requiring Texas Health and Human Services Commission (HHSC) to monitor the provider networks of managed care organizations. Texas Children’s Health Plan would like to ensure members are able to schedule appointments with providers in accordance with the HHSC’s appointment accessibility guidelines.
| Provider type | level/type of care | appointment availability standards |
| OB/GYN | · Emergency services
· Urgent condition
· Prenatal care for initial appointments
· Prenatal care for initial appointments for high-risk pregnancies or new members in third trimester
· Appointments for ongoing OB care must be available in accordance to treatment plan as developed by the provider |
Immediately
Within 24 hours
14 days
Initial appointment must be offered within 5 days, or immediately, if emergency exists
Must be available in accordance to the treatment plan as developed by the provider |
| Primary Care Physicians | · Emergency services
· Urgent condition
· Primary routine care
· Preventive health services for adult members
· Preventive health services for members less than 6 months of age
· Preventive health services for members 6 months through age 20
· New members 20 years of age or younger to receive a Texas Health Steps checkup |
Immediately
Must be provided within 24 hours Within 14 days
Within 90 calendar days
Offered as soon as possible but no later than 14 days of enrollment for newborns
Must be provided within 60 days
Within 90 days of enrollment |
| Specialty Care | · Emergency services
· Urgent condition
· Specialty routine care must be provided within 21 days |
Immediately
Must be provided within 24 hours 21 days |
| Behavioral Health | · Emergency services
· Urgent condition
· Care for non-life threatening emergency – Behavioral Health
· Initial visit for routine care – Behavioral Health
· Follow-up routine care – Behavioral Health
· Initial outpatient behavioral health visit (This does not apply to CHIP Perinate members) |
Immediately
Within 24 hours
Within 6 hours
10 days
90 days
14 days |
AFTER HOURS: Primary Care Physicians Accessible 24 hours a day, seven days a week, must return call within 30 minutes.
Acceptable: Telephone is answered after-hours by answering service and meets the language requirement of the major population groups which can contact the PCP or another designated medical practitioner. All calls answered by an answering service must be returned within 30 minutes.
The office telephone is answered after normal business hours by a recording in the language of each of the major population groups served, directing the patient to call another number to reach the PCP or another Provider designated by the PCP. Someone must be available to answer the Designated Provider’s telephone. Any other recording is not acceptable.
The office telephone is transferred after office hours to another location where someone will answer the telephone and be able to contact the PCP or another designated medical practitioner, who can return the call within 30 minutes.
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