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Medicaid Managed Care PCPs: Access and Availability
10/1/2019 • Posted by Provider Relations

Primary Care Providers (PCPs) (Family Practice, Internal Medicine, Obstetrics/Gynecology (OB/GYN), Pediatricians) who contract with Fidelis Care (Medicaid Managed Care (MMC) Plan) must meet specific appointment and availability standards to ensure that enrolled Medicaid members have appropriate access to necessary health care. New York State routinely completes surveillance activities to evaluate compliance with the following appointment availability standards, (Medicaid Model Contract 15.2, Appointment Availability Standards):

     •    For urgent care: within twenty-four (24) hours of request.
     •    Non-urgent "sick" visit: within forty-eight (48) to seventy-two (72) hours of request, as clinically indicated.
     •    Routine non-urgent, preventive appointments except as otherwise provided in this Section: within
           four (4) weeks of request.
     •    Initial prenatal visit: within three (3) weeks during first trimester, within two (2) weeks during the second
           trimester and within one (1) week during the third trimester.
     •    Adult baseline and routine physicals: within twelve (12) weeks from enrollment.
     •    Well child care: within four (4) weeks of a request;
     •    Initial family planning visits: within two (2) weeks of request.
     •    Members must reach a live voice when calling a provider after-hours (i.e. an answering service).

Fidelis Care’s MMC Plan requires its contracted PCPs and OB/GYNs to have the primary responsibility serving as the after-hours "on-call" telephone resource to members with medical problems. Providers should not routinely refer calls to an emergency room, unless the Medicaid member is experiencing a life-threatening health emergency.

Please Note: Providers are required to schedule appointments in accordance with appointment and availability standards noted above to be determined compliant with access to care requirements when contacted by an MMC Plan member. Providers must not require a new patient to complete prerequisites to schedule an appointment, such as:

     •    a copy of their medical record;
     •    a health screening questionnaire; and/or
     •    an immunization record.

The provider may request additional information from the new Medicaid member, if the appointment is scheduled at the time of the telephone request. The Department considers prerequisites to scheduling appointments as barriers in gaining access to health care services. Medicaid PCPs are advised to contact the MMC Plan if they are having difficulty meeting the above appointment and availability standards.

If you have any questions, please contact the Fidelis Care Provider Call Center at 1-888-FIDELIS (1-888-343-3547) or contact your Provider Relations Representative.
 

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Each day, Fidelis Care's Utilization Management (UM) Department makes decisions on numerous health insurance claims. These decisions are based only on appropriateness of care and the existence of coverage. 

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