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7.1.7.1 Continuous Access
Continuous access is an important feature of Medicaid Managed Care. Twenty-four-hour primary care provider availability enables clients to access and use services appropriately, instead of relying on ERs for after-hours care.
Continuous access can be provided through direct access to a primary care provider's office and/or through on-call arrangements with another office or service. Clients should be informed of the primary care provider's normal office hours and should be instructed how to access urgent medical care after normal office hours.
After-Hours Guidelines
Primary care providers are required to have at least one of the following arrangements in place to provide 24-hour, 7-day a week access for managed care clients:
• An office phone answered after hours by a medical exchange or a professional answering service. If an answering service is used, the following must be met:
•The answering exchange or service must be able to contact the primary care provider or a designated back-up provider for immediate assistance.
•The primary care provider, or designated back-up provider, must be notified of all calls.
•All calls must be returned in a timely manner by the primary care provider or designated back-up.
•The answering service must meet the language requirements of the major Medicaid population groups in the primary care provider's area.
•An office phone answered after office hours by an answering machine that instructs the client (in the language of the major Medicaid population groups) to do one of the following:
•Call the name and phone number of a medical facility where the client can request to speak with a medical professional to determine whether emergency treatment is appropriate.
•Call another number where the primary care provider can be reached.
•Call the name and phone number of a medical professional serving as designated back-up. In this situation, the client must be able to speak with the back-up provider or a clinician who can offer immediate assistance.
•An office phone transferred after hours to another location where someone will answer and be able to contact the primary care provider or designated back-up provider
Unacceptable Phone Arrangements
The telephone answering procedures listed below are not acceptable:
•An office phone that is answered only during office hours.
•An office phone that is answered by a recording or an answering service that directs clients to go to the ER.
•An office phone answered after hours by an answering machine recording that tells clients to leave a message.
•An office phone answering machine recording that informs clients of regular office hours and requests that they call back during those hours.
•PCCM providers may not direct clients to call the PCCM nurse helpline in order to meet the primary care provider 24-hour continuous coverage requirements.
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