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PAP904

Service Availability and Access to Care


Provider Administrative Policy

Section
Behavioral Health
Policy Date
November 2009
Status/Date
Revised/January 2010
Provider Type(s)
Mental Health  

Disclaimer

Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts.

Policy

Service Availability and Access to Care

Behavioral Health Operational Definitions

Routine
An appointment for any non-acute, non-life threatening symptom that does not interfere with the patient’s ability to function. These symptoms may be mild in nature or ongoing. Appointment examples include, non-acute counseling and follow-up.

Urgent
An appointment for any non-life threatening symptom that is sufficiently bothersome or of recent onset. An example includes, but is not limited to the following condition: The member exhibits significant subjective distress symptoms of a psychiatric disturbance that is not life-threatening and presents no actual or imminent danger of harm or psychosis.

Non Life-Threatening Emergency
Involves members undergoing acute crisis and who need to be stabilized to prevent future deterioration.

Emergency
Involves any severe symptom or accident requiring immediate medical or psychiatric attention for which a delay in care would be life threatening.

Access to Care
Blue Cross of Idaho has adopted the access standards of the National Committee for Quality Assurance (NCQA), and our appointment access standards include office wait times. Providers should see members within the timeframes listed below based on the severity of their clinical presentation:

 Event Timeframe 
 Office wait time 15 minutes or less
 Routine visit Within 10 business days
 Urgent As soon as possible but not to exceed 48 hours
 Non-Life-Threatening Emergency  As soon as possible but not to exceed 6 hours
 Life-Threatening Emergency Seen immediately
 Discharge from Inpatient Level of Care  Within 7 business days

The provider must make every effort to ensure compliance by seeing patients within these access standard timeframes. If the provider is unable to schedule a patient visit within the access standard timeframe, immediately refer the patient to the online practitioner directory or contact Blue Cross of Idaho for an alternative referral.

On-Call and After-Hours Coverage
The provider must arrange to assist members in emergencies 24 hours a day, seven days a week be discussing the following during the initial patient visit:

  • Office hour
  • What is emergency vs. routine vs. urgent
  • What is expected of the member if an emergency, routine or urgent situation arises. 
  • Time frame of response if member leaves message for provider afterhours.
  • Directions for the member if the situation is an emergency situation

If provider is going to be out of the office for an extended period of time, make an arrangement with a colleague to cover patients in the event a need arises for the patient to seek services, in lieu of referring the patient to the emergency room.  Notify patients of this arrangement via message or answering service.

We do not consider general referrals to emergency room settings for all access standards other than nonlife-threatening and life-threatening emergencies appropriate crisis coverage. 

Contact your provider relations representative for contract information (see PAP100).


Policy History

Date Action Reason
January 2010 Revised Further clarified after hours care

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