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Mercy Care conducts Provider Appointment Availability Audits as a requirement under AHCCCS Contractor Operations Manual (ACOM) Policy 417. The data collected is not only used for the regulatory requirement for AHCCCS but it is also used for NCQA accreditation and as a method to ensure sufficient provider network capacity on a regular basis.
The parameters in which audits are performed are to assess the availability of routine and urgent appointments for primary care, specialist, dental, behavioral health providers, and behavioral health appointments for persons in the legal custody of the Department of Child Safety (DCS) and adopted children. We review the availability of routine and urgent appointments for maternity care providers relating to the first, second, and third trimesters, as well as high risk pregnancies. We also conduct audits for medically necessary non-emergent transportation to ensure that a member arrives on time for an appointment, but no sooner than one hour before the appointment; nor have to wait more than one hour after the conclusion of the treatment for transportation home. An appointment available to be delivered through telehealth is considered an available appointment where clinically appropriate.
Appropriate methods for conducting these reviews include:
- Appointment schedule review that independently validates appointment availability.
- Secret shopper phone calls that anonymously validates appointment availability.
- Other methods approved by AHCCCS.
The appointment standards are as follows:
For Primary Care Provider Appointments:
- Urgent care appointments as expeditiously as the member’s health condition requires but no later than two business days of request; and
- Routine care appointments within 21 calendar days of request.
For Specialty Provider Appointments, including Dental Specialty:
- Urgent care appointments as expeditiously as the member’s health condition requires, but no later than two business days from the request; and
- Routine care appointments within 45 calendar days of referral.
For Dental Provider Appointments:
- Urgent appointments as expeditiously as the member’s health condition requires, but no later than three business days of request;
- Routine care appointments within 45 calendar days of request; and
- For CHP only, routine care appointments within 30 calendar days of request.
For Maternity Care Provider Appointments, initial prenatal care appointments with the provider for enrolled pregnant members shall be provided as follows:
- First trimester - within 14 calendar days of request;
- Second trimester - within seven calendar days of request;
- Third trimester - within three business days of request; and
- High risk pregnancies as expeditiously as the member’s health condition requires and no later than three business days of identification of high risk by the Contractor or maternity care provider or immediately if an emergency exists.
For Psychotropic Medication Appointment Standards for all Contractors as follows:
- Assess the urgency of the need immediately.
- Provide an appointment, if clinically indicated, with a practitioner who can prescribe psychotropic medications within a timeframe that ensures the member:
- Does not run out of needed medications; or
- Does not decline in their behavioral health condition prior to starting medication, but no later than 30 calendar days from the identification of need.
For General Behavioral Health Appointment Standards for ACC, ACC-RBHA, ALTCS E/PD and DD Contractors as follows:
- Urgent need appointments as expeditiously as the member’s health condition requires but no later than 24 hours from identification of need;
- Routine care appointments:
- Initial assessment within seven calendar days of referral or request for service;
- The first behavioral health service following the initial assessment as expeditiously but:
- For Members aged 18 years or older, no later than 23 calendar days after the initial assessment; and
- For members under the age of 18 years old, no later than 21 days after the initial assessment.
- All subsequent behavioral health services, condition requires but no later than 45 calendar days from identification of need.
For Behavioral Health Appointment Standards for Persons in Legal Custody of the Arizona Department of Child Safety and Adopted Children in Accordance with A.R.S. § 8-512.01 as follows:
Behavioral health appointments standards for:
- Rapid response - When a child enters out-of-home placement within the timeframe indicated by the behavioral health condition, but no later than 72 hours after notification by DCS that a child has been or will be removed from their home;
- Initial assessment - Within seven calendar days after referral or request for behavioral health services;
- Initial appointment - Within timeframes indicated by clinical need, but no later than 21 calendar days after the initial assessment; and
- Subsequent Behavioral Health Services - Within the timeframes according to the needs of the person, but no longer than 21 calendar days from the identification of need.
The appointment standards for members in the legal custody of the DCS and adopted children are intended to monitor appointment accessibility and availability. For additional information on behavioral health services for persons in the legal custody of DCS and adopted children in accordance with A.R.S. § 8-512.01, refer to ACOM Policy 449.
For review of ACOM Policy 417 and all other Administrative, Claims, Financial, and Operational Policies of the AHCCCS Administration, feel free to visit: https://www.azahcccs.gov/shared/ACOM/.
The AHCCCS Medical Policy Manual (AMPM) provides information to Contractors and Providers regarding services that are covered within the AHCCCS program. The AMPM should be referenced in conjunction with State and Federal regulations, other Agency manuals [AHCCCS Contractors' Operations Manual (ACOM) and the AHCCCS Fee-for-Service Manual], and applicable contracts. For review of AMPM Policies visit: https://www.azahcccs.gov/shared/MedicalPolicyManual/.
As always, don't hesitate to contact your Mercy Care Network Management Representative with any questions or comments. You can find this notice and all other provider notices on our Mercy Care website.
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