• Access and Availability Form

  • Affinity Health Plan maintains provider access, visit scheduling, and waiting time standards that comply with New York State (NYS) regulations. Affinity and the New York State Department of Health (NYSDOH) actively monitor adherence to these standards. Affinity conducts audits of provider appointment availability, office waiting times, and 24-hour access and coverage. All participating providers are expected to provide care for their Affinity patients within these access guidelines.

    This chart highlights the NYS standard timeframes for access and availability. It is required that you at least meet these standards. If you want to improve member satisfaction and provide an excellent patient experience, you should aim to exceed the standards and accommodate the patient’s preferences.

    Type of Service Timeeframe Standards

    Emergency Care: An emergency condition is defined as a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity including severe pain, which a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in: a) placing the health of the person afflicted with such condition in serious jeopardy, impairment, dysfunction, and disfigurement, or b) placing the health of others in serious jeopardy, in the case of a behavioral condition.

    Care must be provided immediately upon presentation at the service delivery site.

    Urgent Care: Urgent conditions are defined as those illnesses and injuries of a less serious nature than emergencies that require services to prevent a serious deterioration of a member’s health, which cannot be delayed without imposing undue risk to the patient’s well-being, until the patient either returns to the Plan’s service area or until the patient can secure services from his or her PCP.

    Urgent medical or behavioral problems must be seen within 24 hours of request.

    Non-Urgent Sick Visits: These are visits for symptomatic conditions which are neither of an emergency nor an urgent nature.

    Appointment must be scheduled within 48-72 hours of request as indicated by the nature of the clinical problem.

    Routine Care: These visits are for routine management of clinical conditions or other follow-up care as is clinically appropriate.

    Appointment must be scheduled within 4 weeks of request.

    Adult Baseline and Routine Physicals

    Appointment must be scheduled within 12 weeks of enrollment.

    Well-Child Care Visits

    Appointment must be scheduled within 4 weeks of request.

    Initial Prenatal Visits:

    • First Trimester
    • Second Trimester
    • Third Trimester
     

    Appointment must be scheduled within 3 weeks of request.

    Appointment must be scheduled within 2 weeks of request.

    Appointment must be scheduled within 1 week of request.

    Initial Newborn Visit to the PCP

    Appointment must be scheduled within 2 weeks of hospital discharge.

    Initial Family Planning Visits

    Appointment must be scheduled within 2 weeks of request.

    Non-Urgent Referred Specialist Visits

    Appointment must be scheduled within 4 to 6 weeks of request.

    In-Plan Behavioral Health or Substance Abuse Follow-up Visits (subsequent to an emergency or inpatient stay)

    Appointment must be scheduled within 5 days or as clinically indicated.

    In-Plan Non-Urgent Behavioral Health or Substance Abuse Visits

    Appointment must be scheduled within 2 weeks of request.

    Assessments for the purpose of making recommendations regarding ability to perform work when requested by an LDSS

    Appointment must be scheduled within 10 days of request for MMC members.

    Affinity conducts audits of provider demographics, provider appointment availability, and 24-hour access and coverage. All participating providers are expected to provide care for their Affinity members within these access standards.

    Office Hours

    Medicaid Managed Care and CHPlus PCPs must practice at least two days per week and maintain a minimum of 16 office hours per week at each primary care site. HIV specialist PCPs working at academic institutions may have some flexibility with this requirement. Providers who care for the homeless are not required to maintain a minimum of 16 office hours per week at each primacy care site.

    24-Hour Coverage

    Participating providers must be accessible 24 hours a day, seven days a week throughout the year either directly or through back-up coverage arrangements with other Affinity participating providers. Each Affinity provider must have an on-call coverage plan acceptable to Affinity that outlines the following information:

    • Regular office hours including days, times and locations
    • After-hours telephone number and some type of service covering the telephone line (e.g., answering service)
    • Providers who take after-hours calls

    Facilities as well as individual practitioners must conform to the following requirements:

    • Affinity members will be provided with a telephone number to use for contacting providers after regular business hours. Telephone operators receiving after-hours calls will be familiar with Affinity and its emergency care policies and procedures, and will have key Affinity telephone numbers available at all times.
    • Affinity providers will be contacted and patched directly through to the member, or the provider will be paged and will call the member back within 30 minutes.
    • Affinity providers must be able to act in accordance with Affinity’s emergency policies and procedures, such as notifying Medical Management of emergency care or admissions.

    Affinity members must be able to locate an Affinity participating provider or a designated covering provider. It is not acceptable to have an outgoing answering machine message that directs members to the emergency room in lieu of appropriate contact with the provider or covering provider. If an answering machine message refers a member to a second phone number, that phone line must be answered by a person.

    Waiting Time Standards

    In addition to access and scheduling standards, Affinity providers are expected to adhere to the following site-of-care waiting time standards:

    • Emergency Visits: Affinity members are to be seen immediately upon presentation at the service delivery site.
    • Urgent Care and Urgent Walk-In Visits: Affinity members should be seen within one hour of arrival. Please note that prescription refill requests for medications to treat chronic conditions are considered urgent care. It is essential that these medications be dispensed to Affinity members promptly to avoid any lapse in treatment with prescribed pharmaceuticals.
    • Scheduled Appointments: Affinity members should not be kept waiting for longer than one hour.
    • Non-Urgent Walk-In Visits: Affinity members with non-urgent care needs should be seen within two hours of arrival, or scheduled for an appointment in a time frame consistent with Affinity’s scheduling guidelines.

    Missed Appointments

    Affinity expects providers to follow up with members who miss scheduled appointments to ensure that Affinity members receive assistance and that compliance with scheduled visits and treatments is maintained.

    At the time an appointment is scheduled, confirm a contact telephone number with the Affinity member. If the member does not keep the scheduled appointment, document the occurrence in the member’s medical record and attempt call the member.

    To encourage member compliance and minimize the occurrence of “no shows,” provide a return appointment card to each member for the next scheduled appointment.