Are you meeting access standards?

Primary care providers must be accessible to Texas Children’s Health Plan members 24 hours a day, 7 days a week. Acceptable after-hours coverage includes:

1. The office telephone is answered after-hours by an answering service that meets language requirements of the major population groups and that can contact the PCP or another designated medical practitioner. All calls answered by an answering service must be returned within 30 minutes.
2. The office telephone is answered after normal business hours by a recording in the language of each of the major population groups served, directing the patient to call another number to reach the PCP or another provider designated by the PCP. Someone must be available to answer the designated provider’s telephone. Another recording is not acceptable.
3. The office telephone is transferred after office hours to another location where someone will answer the telephone and be able to contact the PCP, or another designated medical provider, who can return the call within 30 minutes.

Unacceptable after-hours coverage includes:

1. The office telephone is only answered during office hours.
2. The office telephone is answered after-hours by a recording that tells patients to leave a message.
3. The office telephone is answered after-hours by a recording that directs patients to go to an Emergency Room for any services needed.
4. Returning after-hours calls outside of 30 minutes.

Texas Children’s Health Plan will randomly audit providers to ensure members have access to PCPs 24/7 and will notify providers if the resulting audit requires a modification.