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Sanford Health Plan

Timeliness of Care Survey results and A&A Standards

Sanford Health Plan takes pride to ensure that our members have proper access and availability to quality health care providers. We feel it is important to monitor the established policies and procedures of Plan participating providers to ensure member access to medical care and services is timely and appropriate. The criteria for appropriate access and availability included in these policies are below.

Primary Care standards:

  • PCPs and specialty physicians are required to be accessible to Plan members 24 hours per day, seven days per week. Accessibility may occur through membership in 24-hour available call groups or other arrangements permitted by the Plan.
  • PCPs are required to have a 24-hour answering service with standards for maximum allowable call-back times based upon what is medically necessary.
  • PCPs are required to respond to a member’s call after hours within 30 minutes of the initial call.
  • PCPs are required to provide back-up coverage from a physician who must meet the same standards of practice as participating physicians.
  • PCPs are expected to see emergency cases the same day or to refer them to an emergency facility.
  • PCPs are expected to see urgent cases (but non-emergent) within 24 hours. Urgent care is defined as medically necessary care for an unexpected illness or injury which is less severe than an emergency condition but which requires prompt medical attention within 24 hours.
  • PCPs are expected to see non-urgent sick care cases within 72 hours.
  • PCPs are expected to see routine and preventive cases (i.e. cases which are not emergent or urgent) within six weeks of request.
  • PCPs are encouraged to schedule early, periodic screens, diagnostic tests and other evaluations of children.
  • PCPs are encouraged to ensure that waiting time in the PCP’s office does not exceed 30 minutes.
  • PCPs are required to have office staff that is courteous, timely and responsive to the needs of our members.

Maternity standards:

  • Providers are expected to see emergency cases immediately.
  • Providers are expected to have first trimester initial visit within 14 days of first request.
  • Providers are expected to have second trimester initial visit within seven days of first request.
  • Providers are expected to have third trimester initial visit within three days of first request.

Behavioral/Mental Health and/or Substance Use Disorder standards:

  • These providers are required to be accessible to Plan members 24 hours per day, 7 days per week. Accessibility may occur through membership in 24-hour available call groups or other arrangements permitted by the Plan.
  • These providers are expected to see a member with life-threatening emergency needs immediately.
  • These providers are expected to see a member with non-life-threatening emergency needs within six hours.
  • These providers are expected to see a member with urgent needs within 48 hours.
  • These providers are expected to see a member for an initial visit for routine care within ten working days.
  • These providers are expected to see a member for a routine follow-up visit within 30 days

To measure compliance with the NCQA required standards, a phone survey was conducted by Health Plan Care Management staff. The survey sampled Primary Care providers, five percent of Behavioral/Mental Health and/or Substance Use disorder prescribing and non-prescribing providers, five percent of Maternity/OBGYN providers, five percent of High-Volume Specialty providers (excluding maternity/OBGYN since this is assessed in a separate sample), and five percent sample of High-Impact Specialty providers (excluding maternity/OBGYN since this is assessed in a separate sample). Health Plan staff asked what appointment options were offered for patients with emergent, urgent and routine needs. Staff also inquired about clinics’ coverage for after hours and on-call providers. The standards listed above applied to all practitioner types. Specialty standards applied to each type of high volume and high impact specialty noted in the definitions. Congratulatory letters were sent to those clinics meeting the standards. Letters were also sent to clinics not meeting the standards, and action plans were requested from them. Provider Relations Department follows up with these clinics after three months to measure compliance with the failed standard(s).

Compliance rates for PCP clinics:

  • Urgent condition: 85.19% (compared to 100% overall access rate last year)
  • Urgent but non-emergent condition: 74.07% (compared to 98% overall access rate last year)
  • Routine preventive visit: 96% (compared to 95% overall access rate last year)
  • After hours coverage: 98% (compared to 100% last year)

Compliance rates for behavioral health clinics:

  • Non-life-threatening behavioral health emergency: 80.59% (compared to 81% overall access rate last year)
  • Urgent behavioral health needs: 92.11% (compared to 90% overall access rate last year)
  • Routine behavioral health visit: 62.34% (compared to 94% overall access rate last year)
  • New patient behavioral health visit: 59.21% (compared to 61% overall access rate last year)
  • After hours coverage: 92.11% (compared to 100% last year)

Compliance rates for Maternity clinics:

  • Emergent: 75% (compared to 100% overall access rate last year)
  • Initial Prenatal Care – First Trimester: 75% (compared to 80% overall access rate last year)
  • Initial Prenatal Care – Second Trimester: 75% (compared to 73.3% overall access rate last year)
  • Initial Prenatal Care – Third Trimester: 68.75% (compared to 80% overall access rate last year)
  • Initial High Risk Pregnancy: 75% (compared to 77.8% overall access rate last year)
  • After hours coverage: 81.25% (compared to 77.8% overall access rate last year)

Compliance rates for High Volume Specialist clinics:

  • New patient visit: 92.11% (compared to 94.4% overall access rate last year)
  • After hours coverage: 94.74% (compared to 77.8% overall access rate last year)

Compliance rates for High Impact Specialist clinics:

  • New patient visit: 100% (compared to 96.3% overall access rate last year)
  • After hours coverage: 90.91% (compared to 88.9% overall access rate last year)

There were no access related member complaints or appeals in the last year.
Clinics and participating providers will continue to receive education regarding the standards through the provider newsletter. All clinics in the survey received follow up letters with their clinic’s results as well as a copy of the Plan’s access standards. The clinics that failed to meet the appointment access standards were asked to create an action plan. Clinics are informed that members must be able to make appointments. Clinics must make accommodations if and when schedulers are unavailable.

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