Responsibilities to members

Contracted personal physicians or primary care providers are responsible for providing members with medically necessary services, either directly or by referral to other contracted providers.

Personal physicians are responsible for supporting appropriate member access to care. They must comply with the following appointment wait-time standards and emergency services requirements, which we based on standards set forth by Medicare but are applicable to all members.

Non-symptomatic (preventive): Office visits shall be available from the member's personal physician or an alternative provider within 30 calendar days.

Non-urgent symptomatic: Office visits shall be available from the member's personal physician or an alternative provider within seven calendar days.

Urgent: Office visits shall be available within 24 hours.

Emergent: Care shall be available 24 hours per day, seven days per week.

In-office wait times: In-office wait times for primary care physician (PCP) appointments must be reasonable and should not be greater than wait times for other patients. Wait times are monitored through complaint resolution, surveys, and change request reasons. Interventions are implemented when standards are not met.

Primary 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.

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