Fidelis Care Access and Availability Standards

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:

Situation  Timeframe
Emergency care  Immediately upon presentation at a service delivery site
Urgent care 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-
urgent)
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.