After-hours medical availability
Use one of these methods to help members after regular business hours:
- A professional answering service that contacts you or the provider covering for you
- A high-quality voice mail system that tells members:
- How to reach you or your substitute in an emergency, including phone number(s)
- What do do in an emergency, including local emergency room phone numbers if available
- Rural Behavioral Health Providers may direct members to the emergency room via an answering system only if there is no participating provider in the same field of practice to share on-call coverage.
- Instructions must clearly direct members with non-emergency situations to call the emergency room first.
- The message should also provide the telephone number(s) of the emergency room(s) available in the area.
- If your instructions ask the member to leave a message, you are expected to respond to the message quickly.
Requirements for Priority Health Medicare members
Under its contract with the Centers for Medicare and Medicaid Services (CMS), Priority Health is required to notify all providers that under CFR 422.11(a)(7), they are required to:
Provide services, both clinical and nonclinical, that are readily available, accessible, and appropriate, when medically necessary (24 hours a day/7 days a week) to all enrollees, including those with limited English proficiency or reading skills and those with diverse cultural and ethnic backgrounds. Services include access to specialty care such as women's health services.
More about after-hours services:
- After-hours medical care policy for Priority Health providers, below
- Billing for after-hours primary care services
- Standards for after-hours behavioral health care
Priority Health medical after-hours availability policy
Practitioner accessibility to members after normal business hours is a key indicator of quality of care and service promoted by the National Committee for Quality Assurance, the Michigan Department of Community Health and purchasers of health care.
To ensure that appropriate care is extended to members beyond business hours, Priority Health requires:
All Priority Health-contracted Practitioners will have appropriate after-hours coverage utilizing one of the following methods:
- Answering service that will contact practitioners on behalf of the member.
- Answering machine with explicit directions (including other telephone numbers if necessary) on how to reach a practitioner and action to take in an emergency. The practitioner may ask the member to leave a message but must be able to respond in an expedient manner.
- For rural* Primary Care Practitioners (PCPs), an answering machine may direct the member to call an emergency room in order to have the opportunity to be directed to a covering practitioner. The instructions must clearly direct the member with non-emergent situations to call the emergency room first and provide the member the telephone number(s) of the emergency room(s) available in the area.
*Rural service areas include the following counties: Antrim, Barry, Benzie, Charlevoix, Cheboygan, Crawford, Eaton, Emmet, Grand Traverse, Gratiot, Ionia, Kalkaska, Lake, Leelanau, Manistee, Mason, Mecosta, Montcalm, Montmorency, Newaygo, Oceana, Osceola, Otsego, and Wexford.
- For Specialty Care Practitioners (SCPs), for which no other like in-network practitioner is available to share call, an answering machine may direct the member to call their Primary Care Practitioner or an emergency room in order to have the opportunity to be directed to a covering practitioner. The instructions must clearly direct the member with nonemergent situations to call their Primary Care Practitioner or emergency room first and provide the member the telephone number(s) of the emergency room(s) available in the area.
- Certain types of specialty practices that do not typically incur emergent situations or individual circumstances may be exempt from this requirement. Certain specialties include, but may not be limited to: pathology, dermatology, infectious disease, optometry, chiropractic, etc. Individual circumstances will be taken into account, i.e., certain types of specialty practices, for final compliance determination.
The determination of compliance, in unique or questionable circumstances, will be made by the Director of Corporate Quality Improvement, Medical Director(s), and/or Chief Medical Officer as necessary.
Practitioners who are not compliant to the Administrative standard will be notified of the need to improve after-hours access, by letter, requesting a response within three months of initial contact.
A follow-up random after hours call will confirm action or non-action taken by the practitioner.
Further non-compliance will result in a second letter and continued non-compliance will result in further review by Medical Affairs or Credentialing Committees with potential sanctions implemented.
Application for credentialing, member complaints, office site visits or contacts.