Access and Availability Audits
At least annually, Meridian evaluates the ease that enrollees have in obtaining health care services from Meridian primary care, specialty care, and behavioral health providers. Access to various appointments is defined by State, Federal, and Accrediting bodies. These standards, given below, are also available in the Meridian Provider Manual, which can be found on mimeridian.com under For Providers > Provider Resources > Manuals, Forms, and Resources.
Access and Availability Standards
Office Visit Appointment Standards
- Emergency: Immediately
- Urgent Care: Appointments are scheduled within 48 hours with an available clinician
- Non-Urgent Symptomatic Care: Appointments are scheduled within seven days with an available clinician
- Preventive Care:
- For Adult Preventive Care appointments, schedule within 30 days
- For Children <18 months old, preventive care appointments are available within 2 weeks
- For Children >18 months old, preventive care appointments are available within 4 weeks
- Specialty Care: Appointments are scheduled within 6 weeks with an available clinician
- Acute Specialty Care: Appointments are scheduled within 5 business days with an available clinician
- Mental Health:
- Routine Care: Care is available within 10 business days hours of request
- Non-life-threatening emergency: Care is available within 6 hours of request
- Urgent Care: Care is available within 48 hours of request
- Prenatal Care - Initial Prenatal Appointment
- If enrollee is in first or second trimester: Within 7 business days of enrollee being identified as pregnant
- If enrollee is in third trimester: Within 3 business days of enrollee being identified as pregnant
- If there is any indication of the pregnancy being high risk (regardless of trimester): Within 3 business days
After Hours Access Standards
Meridian has established acceptable mechanisms for use by Primary Care Providers, Specialists, and Behavioral Health providers to ensure telephone access and service for members 24 hours a day. All Primary Care Provider, Specialist, and Behavioral Health provider contracts require providers to provide members with access to care 24 hours a day, seven days a week.
Acceptable after-hours access mechanisms include:
- Answering service
- On-call beeper
- Call forwarded to provider’s home or other location
- Recorded telephone message with instructions for urgent or non-life-threatening conditions. Message must direct members to a practitioner.
There must be a method to talk to a provider 24 hours a day, 7 days a week regarding after-hours care for urgent or non-life-threatening conditions as well as instructions to call 911 or go to the emergency department in the event of a life-threatening condition or serious trauma. This message should not instruct members to obtain treatment at the emergency department for nonlife-threatening emergencies.
Hours of Operation Parity
All Network Providers must offer hours of operation that are no less than the hours of operation offered to commercial members.
Re-Audits
Meridian reserves the right to re-audit any provider if they do not pass the audit at 100%. The initial and re-audits will typically happen in the second and fourth quarters of the year. After Meridian analyzes the results of the appointment access audit, failing providers and associated provider representatives (if applicable), receive follow-up communication, including a notification letter. Providers that failed the initial audit may be re-audited within 6-9 months and this time should be used to correct the appointment timeliness deficiencies. Any failure to resolve the deficiency could result in referral to the Credentialing Committee and/or the Chief Medical Officer for further review and determination of disciplinary actions, if necessary.