All primary care providers are required to maintain 24-hour, seven-day-a-week telephone access for their members.
Under the New York State Medicaid Managed Care and Family Health Plus Model Contract, a primary care provider must practice a minimum of 16 hours a week at each primary care site. All Fidelis Care providers must have an appointment system that meets the following standards for appointment availability for primary care services:
||Immediately upon presentation at a service delivery site
||Within 24 hours
|Non-urgent sick visits
||Within 48-72 hours as clinically indicated
|Routine, non-urgent, or preventive appointments
||Within 4 weeks
|Specialist referrals (non-
|Within 4-6 weeks
|Well child care
||Within 4 weeks
|Initial prenatal visit
||Within 2 weeks for the initial visit, every 2 weeks during the second trimester, and every week thereafter
|Initial PCP office visit for newborns
||Within 2 weeks of hospital discharge
|In-plan mental health or substance abuse
||Within 5 days, or as clinically indicated
|Follow-up visits (pursuant to an emergency or hospital discharge)
||Within 1 week
|Adult baseline and routine physicals
||Within 12 weeks from enrollment (adults > 21 years)
|Non-urgent mental or substance abuse visits with a PCP
||Within 2 weeks
The standard for returning a member call is 30 minutes. It is not acceptable to have an answering machine in place that does not connect directly to the provider. The message must direct the member to a live voice. The primary care provider is responsible for arranging on-call and after-hours coverage to ensure 24-hour telephone access to all members.
Members with appointments should not be made to wait longer than 30 minutes. Walk-in members with urgent needs should be seen within one hour, and walk-in members with non-urgent needs should be seen within two hours, or scheduled for an appointment consistent with the above scheduling guidelines.
Fidelis Care is required to conduct 24-Hour Access and Appointment Availability studies of our providers annually (Semi-annual in New York City) and submit the results to the New York State Department of Health and each Local Department of Social Services (LDSS). In addition, the New York State Department of Health conducts their own survey.
For additional information please refer to Section Four- Primary Care Services of the Fidelis Care Provider Manual.