After hours requirements

Providers have the responsibility to make arrangements for afterhours coverage in accordance with applicable state and federal regulations, either by being available or having on-call arrangements in place with other qualified participating Aetna Better Health of New Jersey providers for the purpose of rendering medical advice, determining the need for emergency and other after-hours services including, authorizing care, and verifying member enrollment with us.

It is our policy that network providers cannot substitute an answering service as a replacement for establishing appropriate on call coverage. On-call coverage response for routine, urgent, and/or emergent health care issues are held to the same accessibility standards regardless if after hours coverage is managed by the PCP, current service provider, or the on-call provider.

All providers must have a published after hours telephone number and maintain a system that will provide access to primary care 24/7. In addition, we encourage our providers to offer:

  • Open access scheduling, and
  • Expanded hours and alternative options for communication (e.g., scheduling appointments via the web, communication via e-mail) between members, their PCPs, and practice staff

 

We routinely measure PCP’s compliance with these standards as follows:

  • Our medical and provider management teams will continually evaluate emergency room data to determine if there is a pattern where a PCP fails to comply with after-hours access or if a member may need care management intervention.
  • Our compliance and provider management teams will evaluate member, caregiver, and provider grievances regarding after hour access to care to determine if a PCP is failing to comply on a monthly basis.

 Providers must comply with telephone protocols for all of the following situations:

  • Answering the member telephone inquiries on a timely basis.
  • Prioritizing appointments
  • Scheduling a series of appointments and follow-up appointments as needed by a member.
  • Identifying and rescheduling broken and no-show appointments.
  • Identifying special member needs while scheduling an appointment, e.g., wheelchair and interpretive linguistic needs.
  • Triage for medical and dental conditions and special behavioral needs for noncompliant individuals who are mentally deficient.
  • Response time for telephone call-back waiting times: after hours telephone care for non-emergent, symptomatic issues - within 30 to 45 minutes; same day for non-symptomatic concerns; 15 minutes for crisis situations.
  • Scheduling continuous availability and accessibility of professional, allied, and supportive medical/dental personnel to provide covered services within normal working hours. Protocols shall be in place to provide coverage in the event of a provider’s absence.

A telephone response should be considered acceptable/unacceptable based on the following criteria:

Acceptable - An active provider response, such as:

  • Telephone is answered by provider, office staff, answering service or voicemail
  • The answering service either:
    • Connects the caller directly to the provider
    • Contacts the provider on behalf of the caller and the provider returns the call
    • Provides a telephone number where the provider/covering provider can be reached
  • The provider’s answering machine message provides a telephone number to contact the provider/covering provider

Unacceptable:

  • The answering service:
    • Leaves a message for the provider on the PCP/covering provider’s answering machine; or
    • Responds in an unprofessional manner.
  • The provider’s answering machine message:
    • Instructs the caller to go to the emergency room, regardless of the exigencies of the situation, for care without enabling the caller to speak with the provider for non-emergent situations.
    • Instructs the caller to leave a message for the provider.
  • No answer
  • Listed number no longer in service
  • Provider no longer participating in the contractor’s network
  • On hold for longer than five minutes
  • Answering Service refuses to provide information for survey
  • Telephone lines persistently busy despite multiple attempts to contact the provider

Provider must make certain that their hours of operation are convenient to, and don’t discriminate against, members. This includes offering hours of operation that are no less than those for non-members, commercially insured or public fee-for-service individuals.

In the event that a PCP fails to meet telephone accessibility standards, a Provider Services Representative will contact the provider to inform them of the deficiency, educate the provider regarding the standards, and work to correct the barrier to care.