Peach State Provider Office Manual - Peach State Health Plan ...

PCP AVAILABILITY AND ACCESSIBILITYEach participating physician shall maintain sufficient facilities and personnel to provide coveredphysician services and shall ensure that such services are available as needed twenty-four (24)hours a day, 365 days a year. All participating providers shall offer hours of operation that are noless than the hours of operation offered to commercial and fee-for-service members. Peach Stateencourages PCPs to offer services after hours and on the weekends.Peach State will monitor physicians’ offices through scheduled and un-scheduled visits throughour Provider Relations staff.PCP COVERAGEThe participating physician shall arrange for coverage with a physician who must have executeda contractual agreement with Peach State. If the participating physician is capitated forprofessional services, compensation for the covering physician is considered to be included in thecapitation payment. If the participating physician is on a fee-for-service agreement with PeachState, the covering physician is compensated in accordance with the fee schedule in his/heragreement.APPOINTMENT AVAILABILITYThe following schedule should be followed regarding appointment availability:• PCP (routine visits) not to exceed fourteen (14) calendar days• PCP (adult sick visit) not to exceed twenty-four (24) hours• PCP (pediatric sick visit) not to exceed twenty-four (24) hours• Specialist visits not to exceed (30) calendar days• Urgent Care Provider not to exceed twenty-four (24) hours• Emergency care services rendered immediately and available twenty-four (24) hours aday, seven (7) days a week and without prior authorization• Dental Provider (routine visits) should not exceed 21 calendar days.• Dental Provider (urgent care) not to exceed 48 hours• Non-emergency hospital stays should be provided within thirty (30) calendar days• Behavioral Health visits should be provided immediately for emergency services, withintwenty-four (24) hours of the request for urgent care, and within fourteen (14) calendardays of the request for routine care• Mental Health Provider visits should be provided within fourteen (14) calendar days.• OB (initial pregnancy visit) appointment should be provided within fourteen (14) days ofthe request.The participating physician shall provide adequate capacity for initial visits for pregnant womenwithin fourteen (14) calendar days and visits for Health Check eligible children within ninety (90)calendar days of the members’ enrollment in Peach State.Peach State will monitor appointment and after-hours availability on an on-going basis through itsQuality Improvement Program.Provider Services1-866-874-063302/22/201117