 |
|
|
Wellmark Health Plan of Iowa has policies to ensure our members have access to care during and after standard office hours. This includes making sure that participating offices provide a way for members to contact clinicians after office hours and on weekends for care or questions about situations that are not life-threatening emergencies, but still of concern.
Our policy is:
Primary care offices will provide or arrange for the provision of covered services to members 24 hours per day, 7 days per week.
Below are descriptions of acceptable and unacceptable ways that primary care practitioner (PCP) offices may provide patient access to care during non-office hours, and assist members in using medical resources appropriately.
Acceptable Methods of Arranging for Primary Care Coverage during Non Office Hours
1. Nurse/Staff Member Answers – The regular office telephone number is answered by an on-call, triage, or advice nurse or staff member with direct access to the on-call PCP (i.e., PCP’s phone or pager number is given, or the nurse or staff member pages or calls the PCP).
2. Direct Access to Primary Care Practitioner – Clinician answers – The regular office telephone number is answered by a PCP after hours.
3. Answering Service – The regular telephone number is answered by an answering service which patches the call through to an on-call PCP.
4. Answering Service – The regular office telephone number is answered by an answering service which takes a message and pages the PCP, who then returns the patient’s call.
5. Answering Service – The regular office telephone number is answered by an answering service which patches the call through to a triage nurse who has access to the on-call PCP.
6. Answering Service – The regular office telephone number is answered by an answering service which instructs the member to call the on-call PCP directly and provides a telephone number or pager number.
7. Answering Machine – The regular office telephone number is answered by an answering machine which instructs the member to call (not go to) a local hospital emergency room and provides the phone number. This option assumes the hospital has agreed to provide triage services for the primary care office when the office is closed, and that the services of a PCP are immediately available should they be required.
8. Answering Machine – The regular office telephone number is answered by an answering machine which instructs the member to seek care (call or go to) a local urgent care center. The message must include the urgent care center’s telephone number and hours of operation (must give both). If the urgent care center closes before the primary care office reopens, the member must be offered one of the alternative acceptable options.
8. Answering Machine – The regular office telephone number is answered by an answering machine which instructs the member to seek care (call or go to) a local urgent care center. The message must include the urgent care center’s telephone number and hours of operation (must give both). If the urgent care center closes before the primary care office reopens, the member must be offered one of the alternative acceptable options.
9. Answering Machine – The regular office telephone number is answered by an answering machine which instructs the member to call the on-call PCP physician directly and provides a telephone number or pager number.
10. Answering Machine – The regular office telephone number is answered by an answering machine which, in addition to providing office hours and/or instructions for receiving emergency care, instructs the member to call an answering service and provides the phone number.
11. Answering System Gives A Number For An Answering Service – The regular office telephone number is answered by an on-call, triage, or advice nurse with direct access to the on-call PCP.
12. Answering System Gives A Number For An Answering Service – The regular telephone number is answered by an answering system which provides a number to an answering service, which in turn patches the call through to an on-call PCP.
13. Answering System Patches Call Through to PCP – The regular telephone number is answered by an answering system which patches the call through to an on-call PCP.
14. Answering System Gives A Number For An Answering Service – The regular office telephone number is answered by an answering system which instructs the member to call the answering service and provides a phone number, or enables the caller to call the on-call PCP and provides a telephone number or pager number.
Unacceptable Methods of Arranging for Primary Care Coverage during Non-Office Hours
1. Answering Machine - An answering machine that only takes messages.
2. Answering Machine - An answering machine with a message that recommends calling back during business hours or, if this is an emergency, call 911. There is no mention of how to reach a PCP if the situation is not an emergency.
3. Nurse/Staff Member Answers - On-call, triage, or advice nurse or staff member without direct access to the on-call PCP (i.e., person doesn’t have a way to reach a PCP— can only take a message).
4. Answering Machine - An answering machine with a message which directs the member to go to a local emergency room.
5. Answering Machine - An answering machine which directs member to an urgent care center but does not give the phone number, hours of operation, or a number to call if the urgent care center closes before the primary care office reopens.
1. An Unanswered Telephone - No answer after 10 rings on second night attempt.
2. Private Residence - Phone rings into private residence.
|
|
|
|
|
|
