Responsibilities to members
Kaiser Permanente works with network providers to ensure that OIC, CMS, and NCQA standards are met regarding patient care. Utilizing these agency guidelines, Kaiser Permanente has established the following standards for access to care, which are detailed below.
Contracted providers are responsible for providing members with medically necessary services. Contracted providers are responsible for appropriate and timely member access to care. They must comply with requests for reporting and meeting the following appointment wait-time standards and emergency services requirements. We understand it may not always be possible to meet these standards due to a community shortage of certain healthcare professionals.
Non-symptomatic (preventive) primary care: Office visits shall be available from the member's personal physician or an alternative provider within 30 calendar days.
Non-urgent symptomatic primary care: Office visits shall be available from the member's personal physician or an alternative provider within 7 calendar days.
Urgent primary care: Office visits shall be available within 24 hours.
Emergent primary care: Direct or coordinated care (outside of office hours) shall be available 24 hours per day, seven days per week. The provider may direct members to use the emergency department outside of office hours for emergent primary care.
Non-urgent specialty care: A member shall be able to obtain an appointment with his or her specialty care provider for non-urgent care within 15 business days of the appointment request.
Urgent specialty care: A member shall be able to obtain an appointment with his or her specialty care provider for urgent care within 48 hours for appointments that do not require prior authorization, or within 96 hours (4 days) of a provider referral for appointments requiring prior authorization.
In-office wait times: In-office wait times for physician appointments must be reasonable. Wait times are monitored through complaint resolution, surveys, and change request reasons. Interventions are implemented when standards are not met.
Physicians are responsible for the following:
- Ensuring that physician services are available 24 hours per day in order to advise members about how and where to obtain necessary care.
- Consulting with emergency department providers about the most appropriate setting for the level of care.
- Authorizing coverage for urgent care in emergency departments, when appropriate.
- Confirming with members their financial responsibility for any non-covered services.
- Identifying, assessing, and establishing treatment plans for members.
- Ensuring that members with special health care needs receive appropriate case management.
- Cooperating with Kaiser Permanente periodic requests for detailed reports pertaining to member access to care.
- Ensuring that notes back to referring providers are timely
- Providing interpretive services as necessary. Please see our Interpretive Services policy for more information.
Content on this page is from the provider manual | Disclaimer