Provider Alert! Regulatory Guidelines & Appointment Availability Standards Reminder

Provider Alert!

Provider Alert! Regulatory Guidelines & Appointment Availability Standards Reminder

Attention: Primary Care and Specialist Providers

Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event.  TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.
 

Call to action: Texas Children’s Health Plan (TCHP) would like to remind network providers of the appointment availability standards and regulatory requirements. 
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. 

How this impacts providers:  Texas Children’s Health Plan enforces access and other network standards required by the contract and takes appropriate action with providers whose performance is determined by the health plan to be out of compliance. In addition, providers and staff are responsible for understanding the requirements.  

  Provider Demographic Changes:  

  • Demographic changes must be sent in writing.  
  • TCHP is not responsible for potential claims processing and payment errors due to failure to update information.  
  • Notification of change can be completed by accessing the form on the provider web page or portal at https://www.texaschildrenshealthplan.org/for-providers, once completed, fax to (832) 825-8750 or emailed to providerrelations@texaschildrens.org .  Here is the form you will need to complete: 

Network providers must also notify TMHP of any demographic changes. The form can be found here:
http://www.tmhp.com/Provider_Forms/Provider%20Enrollment/F00114_Provider_Information_Change_Form.pdf 

Authorizations
Primary Care Providers, a reminder that a referral is not needed to see an in-network specialist.

APPOINTMENT AVAILABILITY STANDARDS  

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 Members 21 years of age or older  
  • 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 

 

  • CHIP Members should receive preventive care in accordance with AAP 
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 

 

 

American Academy of Pediatrics(AAP)  Periodicity Schedule  

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* 

 

 

Within 14 days* 

 

 

Within 90 days* 

 

 

Within 14 days 


*Accessibility Standards set by National Committee for Quality Assurance
 

Next steps for providers: Providers should share the appointment availability standards and regulatory guidelines with their staff and implement internal procedures for compliance, if needed.  

If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org. 

For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers. 

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