REQUIRED: After-Hours, Appointment and Office Site Standards
Date: 07/16/24
As a reminder, Superior HealthPlan conducts assessments regularly to ensure that network providers are meeting the after-hours coverage standards required by the Texas Health and Human Services Commission (HHSC). In-network Primary Care Providers (PCPs) are required to provide access to care and medical advice for enrolled members 24 hours per day, 7 days per week.
To learn more about the after-hours coverage requirement, please review Superior’s Provider Manuals, located on Superior’s Training and Manuals webpage. To review after hours standards, please download the After-Hours Telephone Accessibility (PDF), found under the Quality Resources section, on Superior’s Quality Improvement webpage.
Superior members respond to aspects of availability and ease of getting after-hour appointments on the regulatory Consumer Assessment of Healthcare Providers and System (CAHPS) surveys, which can impact overall member satisfaction. In 2023, our adult Medicaid members reported that 28.6% did not get the needed after-hours care.
In order to assist providers in meeting after-hours coverage standards, providers may refer members to Superior’s 24-hour Nurse Advice Line, a nurse hotline, where members can receive the help they may need.
Please note: Providers are responsible for making modifications to voicemail messages to include the Nurse Advice Line information for Superior members, as needed. It is important to add direction on the after-hours phone message, directing members to call 9-1-1, or visit the nearest hospital or emergency room if they are having an emergency or experiencing a crisis.
The Superior Nurse Advice Line is staffed by registered nurses who are available to answer health-care questions and help Superior members determine if they need to go to the Emergency Room (ER), an Urgent Care Clinic or see their PCP. Please encourage any Superior members that you serve to use the phone numbers below any time, day or night.
The Nurse Advice Line phone numbers are listed below, by product:
Product | Phone |
Ambetter from Superior HealthPlan |
(TTY: 1-800-735-2989) |
CHIP |
(TTY: 1-800-735-2989) |
STAR |
(TTY: 1-800-735-2989) |
STAR Health |
(TTY: 1-800-735-2989) |
STAR Kids |
(TTY: 1-800-735-2989) |
STAR+PLUS |
(TTY: 1-800-735-2989) |
STAR+PLUS Medicare-Medicaid Plan (MMP) |
(TTY: 711) |
Wellcare By Allwell | 1-844-796-6811 (HMO) 1-877-935-8023 (HMO DSNP) (TTY: 711) |
In addition to the after-hours assessments, Superior regularly conducts an assessment of practitioner accessibility and requires providers to maintain appointment availability and office site standards. This helps to ensure members have local access to diverse, qualified practices that are safe, accessible and available to provide quality care. Superior’s goal is to identify opportunities for improvement and eliminate any disparities. Standards are consistent with the National Committee for Quality Assurance (NCQA), Texas Department of Insurance (TDI) and HHSC requirements.
Accessibility to health care is crucial in overall population health. When members are able to obtain quality health care in their area, they are more likely to adhere to treatment guidelines, maintain preventive health practices and receive services when needed the most. Superior maintains a diverse and geographically accessible health-care network by contracting with a wide range of providers, located in areas close to where members reside or work. Geographic accessibility is measured by how physically accessible services and resources are for members. Some factors that are taken into consideration when determining accessibility and developing Superior’s provider network, include:
- Location
- Geographic distribution of the population
- Maximum coverage needed
- Capacity of care for each practitioner
- Environmental barriers
- Available methods of transportation
HHSC requires appointments for certain covered services be available during specified timeframes. Superior monitors appointment availability for routine primary care, specialty care and behavioral health visits annually. The annual audit includes timeframes for urgent care, emergency care and maximum wait times for scheduled and walk-in appointments. Providers must pass with 100% compliance. If compliance is not met, providers will be put on a Performance Improvement Plan. To review Appointment Availability Standards for Superior Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, STAR+PLUS Medicare-Medicaid Plan (MMP), Wellcare By Allwell (HMO and HMO-DSNP) and Ambetter from Superior HealthPlan members, please download the Appointment Availability Standards (PDF), found under the Quality Resources section, on Superior’s Quality Improvement webpage.
Superior has also adopted guidelines for office sites and may conduct on-site visits at any time to ensure compliance. These visits may be initiated by an event or as an investigation of a complaint, and may include evaluating a specific service or facility-related complaint. Any or all performance standards and thresholds may be reviewed during a complaint investigation. In addition, Superior members respond to aspects of appointment availability on the regulatory Consumer Assessment of Healthcare Providers and System (CAHPS) surveys, and this can impact health plan ratings and overall member satisfaction.
Standards for office sites are measured utilizing guidelines in the following areas:
OFFICE SITE MEASURE | GUIDELINES |
Physical Accessibility |
|
Physical Appearance |
|
Adequacy of Waiting and Examination Room Space |
|
Adequacy of Medical/Treatment Record Keeping |
|
For more information regarding geographical access standards, office site surveys or Superior’s adopted guidelines for office sites, please visit Superior’s Quality Improvement webpage.