Quality
The quality of your care matters to us. Read about our appointment standards and more.
Appointment Standards
If you are not able to find an appointment within these time frames, please call customer service for help. You also have the right to file a grievance.
Access to Care Standards
| Physical Health, Behavioral Health, and Substance Use | |
| Type of Care | Timeliness Standard |
| Urgent | Within 24 hours of initial identification of need Urgent is defined as the existence of conditions that are not life-threatening but require expeditious treatment because of the prospect of the condition worsening without clinical intervention. |
| Outpatient follow-up after hospitalization or residential treatment | Within seven days after discharge |
| Non-urgent, symptomatic* *For behavioral health/substance use disorder (SUD), cannot consider administrative or group intake processes as a treatment appointment for non-urgent, symptomatic care or place members on waiting lists for initial requests | Within seven days after request Behavioral health/SUD ongoing outpatient visits: Frequency varies as the member progresses and the type of visit (e.g., therapy session versus medication visit) changes. This should be based on member’s acuity and medical necessity. |
| Physical Health Only | |
| Type of Care | Timeliness Standard |
| Emergency | 24 hours a day availability of information, referral, and treatment of emergency medical conditions |
| Routine (non-symptomatic well-care physical examinations, preventive care) | Within one month after request* *Unless required sooner by AAP Bright Futures schedule |
| Behavioral Health and Substance Use only | |
| Type of Care | Timeliness Standard |
| Emergency (by phone) | Within 15 minutes after initial contact, including TTY accessibility |
| Emergency (in-person) | Urban/suburban areas: within one hour of contact Rural/frontier areas: within two hours of contact |
| Psychiatry/psychiatric medication management- urgent | Within seven days after request |
| Psychiatry/psychiatric medication management- ongoing | Within 30 days after request |
| SUD Residential for Priority populations as identified by Office of Behavioral Health in order: ● Women who are pregnant and using drugs by injection; ● Women who are pregnant; ● Persons who use drugs by injection; ● Women with dependent children; Persons who are involuntarily committed to treatment | Screen a member for level of care needs within two days of request. If admission to the needed residential level of care is not available, refer the individual to interim services, which can include outpatient counseling and psychoeducation, as well as early intervention clinical services (through referral or internal services) no later than two days after making the request for admission. These interim outpatient services are intended to provide additional support while waiting for a residential admission. |
| SUD Residential | Screen a member for level of care needs within seven days of request. If admission to the needed residential level of care is not available, refer the individual to interim services, which can include outpatient counseling and psychoeducation, as well as early intervention clinical services (through referral or internal services) no later than seven days after making the request for admission. These interim outpatient services are intended to provide additional support while waiting for a residential admission. |
Complaints
You have a right to complain. This may also be called a grievance. You can complain if you are unhappy with your service or think you were treated unfairly. Talk to your provider first. You cannot lose your coverage for filing a complaint.
Please let us know if you are unhappy with your providers, services or decisions made about your treatment. An example of a grievance is if the receptionist was rude to you or you couldn’t get an appointment when you needed one. For details on how to file a grievance and what to expect after you file a grievance, please click here.
Appeals
You also have a right to appeal. This means you can ask for review of an action or decision about what services you get. You will not lose your benefits if you file an appeal. You may file an appeal if we deny or limit a type of service you request. You can appeal if we reduce or stop a service that was previously approved. You can also appeal if we deny payment for any part of a service. There are other actions you may appeal. To learn about those actions and how the appeal process works, please click here.
Additional Member Services
Become a Member
Find helpful information about everything from advance directives to health websites and crisis resources.
Helpful Resources
Find general health websites as well as contact information for our partner providers.
Forms & Documents
Quickly access the resources you need. Find everything from grievance forms to reimbursement request forms.
Rights & Responsibilities
It’s important for you to know and understand your rights as well as the things for which you are responsible.