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HomeProvidersHelpful ToolsAccess and Availability

Access and Availability

The New York State Department of Health requires that Primary Care Physicians, OB/GYNs, Oncologists, and Behavioral Health providers adhere to specific Access & Availability Standards, including defined timeframes for various types of care, to ensure timely access for patients. Please refer to the charts below for more details.

Primary Care Physician (PCP)

Appointment Type

Medicaid Requirements

Qualified Health Plans Requirements

Medicare Requirements
Adult Baseline and Routine Physicals Within 12 weeks from enrollment
(adults > 21 years)
Well Child Care Within 4 weeks
Initial PCP Office Visit for Newborns Within 2 weeks of hospital discharge
Routine, Non-Urgent, or Preventive Appointments 4 weeks 15 business days 30 business days
Urgent Care Appointments ≤ 24 hours ≤ 24 hours Immediately
Non-Urgent Mental or Substance Use Disorder Visit with a PCP Within 2 weeks
Non-Urgent Sick Visit 48-72 hours 48-72 hours
Follow-Up Visits (Pursuant to an Emergency or Hospital Discharge) Within 1 week
After-Hours Care 24 hours/7 days a week 24 hours/7 days a week 24 hours/7 days a week

 

Specialists

Appointment Type

Medicaid Requirements

Qualified Health Plans Requirements

Medicare Requirements
Specialists Referrals
(Non-Urgent) 		Within 4-6 weeks
Initial Prenatal Visit Within 3 weeks during 1st trimester, within 2 weeks during 2nd trimester, within 1 week during 3rd trimester
Initial Family Planning Visit Within 2 weeks
High-Volume Specialty Care - OB/GYN (Routine Care) 4 weeks 4 weeks 30 calendar days
High-Volume Specialty Care - OB/GYN (Urgent Care) ≤ 24 hours ≤ 24 hours ≤ 24 hours
High-Impact Specialty Care - Oncology (Routine Care) 4 weeks 30 business days 30 calendar days
High-Impact Specialty Care - Oncology (Urgent Care) ≤ 24 hours ≤ 24 hours ≤ 24 hours

 

Emergency

Appointment Type

Medicaid Requirements

Qualified Health Plans Requirements

Medicare Requirements
Emergency Immediately upon presentation at a service delivery site

Please refer to the General Medical Access and Availability Tip Sheet for more information.

Behavioral Health

Appointment Type

Medicaid Requirements

Qualified Health Plans Requirements

Medicare Requirements
Urgent Care ≤ 24 hours ≤ 48 hours Immediately
Non-Life-Threatening Emergency Mental Health or Substance Use Disorder Visit Emergency appointment within 6 hours Emergency appointment within 6 hours Emergency appointment within 6 hours
Initial Visit for Routine Care ≤ 10 business days ≤ 10 business days ≤ 30 business days
Non-Urgent Routine Visit ≤ 5 business days* ≤ 7 business days ≤ 7 business days
Behavioral Health Specialist Referrals
(Non-Urgent) 		Within 2 weeks for PROS programs (other than clinic)
Within 2-4 weeks for CDT, IPRT, rehab for residential SUD**
CPEP
Inpatient Mental Health
Inpatient Detoxification
Substance Use Disorder (SUD)
Crisis Intervention 		Immediately upon presentation at a service delivery site
Urgently Needed SUD Inpatient
Rehabilitation Stabilization
Treatment Services in OASAS Certified Residential Settings
MH or SUD Outpatient Clinics
Assertive Community Treatment (ACT)
Personalized Recovery Oriented Services (PROS)
Opioid Treatment Programs 		Within 24 hours of request
Follow-up Visit Mental Health or Substance Use Disorder Visit, Routine Within 30 days
Follow-Up Appointment following an Emergency Room or Inpatient Visit ≤ 5 business days

* With participating mental health and/or substance use disorder outpatient clinic provider, including PROS (Personal Recovery Oriented Services) clinic
** CDT - Continuing Day Treatment, IPRT - Intensive Psychiatric Rehabilitation Treatment, SUD - Substance Use Disorder

Please refer to the Behavioral Health Access and Availability Tip Sheet for more information.

Common Compliance Challenges to Avoid

  • Office staff misrepresents the provider as not accepting new patients, not a plan participant, and/or restricted to specialty care or changed specialty.
  • Staff requires previous medical records or a questionnaire be completed before appointment can be made.
  • Provider requires a referral.
  • Provider not at site and no alternative provider available.
  • Inaccurate or outdated phone information.
  • After-hours access challenges are no answer or no answer at the after-hours number. A voicemail with no instruction on how to access non-emergency after-hours care. (Messages that instruct patients to go directly to the hospital are counted as failures.) A voicemail with instruction to leave message for provider, but the callback time was unspecified.

Quick Solutions

  • Confirm Before You Communicate
    Always verify provider status and plan participation before telling a patient “no.” If unsure, offer to call them back with accurate info.

  • Book First, Ask Later
    Don’t let paperwork or referrals delay care. Schedule the appointment first, then guide the patient through what’s needed before the visit.

Wait Time Standards Reminder
  • Members with a scheduled appointment should not be kept waiting more than one hour.

  • Member calls must be returned within 30 minutes.
  • Providers may meet the appointment wait time standards through telehealth services, unless the member specifically requests an
    in-person appointment.
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Demographic Information

To ensure directory accuracy, check your demographic information at fideliscare.org/find-a-doctor. If changes are needed, please visit fideliscare.org/provider-forms to access the Provider Demographic Change Request Form.


Why Your Compliance Matters

Compliance with access and availability standards is essential for delivering timely, quality care. Together, we ensure members get the right care, at the right time, in the right setting.