ACCESSIBILITY/AVAILABILITY: NON-PHYSICIAN SPECIALISTS AND
BEHAVIORAL HEALTH FACILITIES
ADMINISTRATIVE PRACTICE GUIDELINE
PROVIDER TYPE:
Licensed Non-Physician Specialists: Clinical Social
Workers, Psychologists, Professional Counselors, Marriage
and Family Therapists, Behavioral Specialists, Audiologists,
Chiropractors, Dentists, Optometrists, Physical Therapists,
Podiatrists, Speech Therapists, Occupational Therapists,
Clinical Nurse Specialists, Dieticians-Nutritionists,
Independent Certified Registered Nurse Anesthetists,
Independent Certified Registered Nurse Practitioner,
Independent Midwives, Behavioral Health/Chemical Recovery
Free-Standing Facilities*
*Behavioral Health Facilities includes Blue Cross of
Northeastern Pennsylvania
SCOPE:
Services of the Non-Physician Specialist are accessible and
available to members
TARGET POPULATION:
All members
OUTCOME/PROCESS INDICATOR (S):
•
Compliance with one hundred percent (100%) of mandatory indicators as listed in this and
the Facility and Environment guidelines.
•
Compliance with at least seventy percent (70%) of recommended indicators as listed in this
and the Facility and Environment guidelines.
OPERATIONAL DEFINITION (S):
Routine – an appointment for any non-acute, non-life threatening, or non-limb-threatening
symptoms that do not cause any interference with function. These are symptoms of milder nature
or longer duration. Examples include, but are not limited to: previously diagnosed
headache, fatigue, colds, minor injuries, joint/muscle pain, non-acute counseling and
follow-up.
Urgent- an appointment for any non-life threatening or non-limb threatening symptoms that are
sufficiently bothersome or of recent onset. Examples include, but are not limited to the following
conditions: severe abdominal pain, shortness of breath, serious bone/joint injuries, severe
vomiting and severe diarrhea. The member exhibits significant subjective distress symptoms of a
psychiatric disturbance, which is not life-threatening and for which there is not actual or
imminent danger of harm or psychosis.
Non-life Threatening Emergency– (Behavioral Health visits only) - Members undergoing acute
crisis and for whom there is an immediate need to stabilize to prevent further deterioration.
Emergency- Any severe symptoms or accident requiring immediate medical or psychiatric
attention for which delay in care would be life or limb-threatening.
ACCESSIBILITY MANDATORY INDICATOR (S):
•
A routine visit can be scheduled within seven (7) days. Behavioral Health within ten (10)
business days.
•
An urgent visit can be scheduled within twenty-four (24) hours. Behavioral Health within
forty-eight (48) hours.
•
A non-life threatening emergency is seen within six (6) hours for Behavioral Health only.
•
An emergency visit can be seen immediately or directed to the nearest appropriate
emergency facility.
•
Members can be seen for a scheduled appointment within an average of thirty (30) minutes.
AVAILABILITY MANDATORY INDICATOR (S):
•
Each individual Non-Physician Specialist must be available, at a minimum twenty (20)
clinical hours per week in an office(s) located within the Blue Cross of Northeastern
Pennsylvania 13 county service area. Group practices may meet this standard provided they
have the same non- physician specialist type, who is participating, available for appointments
twenty (20) clinical hours per week in an office(s) located within the Blue Cross of
Northeastern Pennsylvania 13 county service area. The following situations require a review
and approval by the Provider Operations Department based on access, availability, business
need and the Credentialing Committee or Credentialing Committee designee’s analysis and
assessment of the applied criteria.
Only has an office located outside of BCNEPA’s 13 county service area
In addition to having an office in the BCNEPA’s 13 county service area, has a nonphysician office outside of BCNEPA’s 13 county service area
Location is other than an office
•
Members who leave messages on an office answering machine will receive a return phone
call within twenty four (24) hours, if applicable.
•
During office hours, automated office answering machine/service will provide instructions to
members calling the office with an emergency.
•
After hours the answering machine/ service will provide the member with explicit directions
on obtaining urgent/emergent care at the most clinically appropriate site.
COVERAGE MANDATORY INDICATOR (S):
•
During non-business hours, the Licensed Behavioral Health Facility must have coverage
arrangements with a twenty-four (24) hour crisis center to handle all calls.
•
Twenty-four (24) hour-a-day coverage is required for podiatric surgeons.
•
Behavioral Health Professionals are required to have a coverage plan for extended absences
that can be individualized according to the needs of each patient.
RECOMMENDED INDICATOR (S):
•
There are written and/or verbal guidelines for telephone answering.
•
While maintaining patient confidentiality, the practice attempts to notify the patient of
missed appointments and the need to reschedule.
TOOL(S):
•
Office Site Evaluation Form for Non Physician Specialists, Psychiatrists and Behavioral
Health Facilities
REFERENCES:
Americans with Disabilities Act of 1990, as amended. Web page review: 1/05, 2/12
National Committee for Quality Assurance Standards and Guidelines for the Accreditation of
MCO’s 2006, 2010, 2012.
Joint Commission Standards for Behavioral Health Care 2008, 2012
Accessibility/ Availability Administrative Practice Guideline for Primary Care Physicians,
Specialist Physicians (including Psychiatrists) and Oral Surgeons, 1/15/08, 11/10
Guidelines for Pennsylvania Standard Site Visit Protocol for Behavioral Health Practitioners
Office Site Evaluation, Draft 1999.
APPLICATION OF PRACTICE GUIDELINE:
This practice guideline applies to the following companies:
First Priority Life Insurance Company®
HMO of Northeastern Pennsylvania (d/b/a First Priority Health®)
APPROVAL:
Approved:
MH/CR Quality Management Committee
Medical Director
Credentialing/Recredentialing Committee
2\16\94, 5\18\94, 11\21\96
5\05\94
5\18\99
Revised:
Credentialing/Recredentialing Committee
Credentialing/Recredentialing Committee
Credentialing Committee (Format changes)
Credentialing Committee
Credentialing Committee
Credentialing Committee
Credentialing Committee
Credentialing Committee
Credentialing Committee
9\21\99
9/18/01
09/17/02
01/21/03
09/16/03
05/18/04
01/18/05
05/15/07
01/15/08
Credentialing Committee (Format changes)
Credentialing Committee
Credentialing Committee
Credentialing Committee
Credentialing Committee
03/16/10
03/20/12
06/19/12
10/16/12
02/18/14