March 2018

Required Medical Appointment Standards

Standards for scheduling appointments follow guidelines published by the American College of Obstetricians and Gynecologists, the National Committee for Quality Assurance and the Texas Health and Human Services Commission. Primary care providers (PCP) and specialists must meet standards for appointment scheduling to ensure members have timely access to medical care and services.

Blue Cross and Blue Shield of Texas monitors provider compliance with appointment access standards on a regular basis. Failure to comply with outlined standards may result in corrective action. PCPs and specialists must make appointments for members from the time of request as follows:

General Appointment Scheduling

• Emergency examinations: immediate access during office hours
• Urgent examinations: within 24 hours of request
• Non-urgent, routine and primary care examinations: within 14 days of request
• Specialty care examinations: within 30 days of request
• Outpatient behavioral health examinations: within 14 days of request
• Routine behavioral visits: within 10 days of request
• Outpatient treatment and post-psychiatric inpatient care: within seven days from date of discharge

Services for Members Under the Age of 21 Years

Well-child Checkup with Assigned PCP

• Within 14 days of enrollment for newborns
• Within 90 days of enrollment for other eligible child members

Preventive Care Visits

• According to the American Academy of Pediatrics periodicity schedule found within the Preventive Health Guidelines and THSteps criteria

Services for Members 21 Years of Age and Older

• Preventive care visit within 90 days of request

Prenatal and Postpartum Visits

• First and second trimesters: Within 14 days of request
• Third trimester: Within five days of request or immediately if an emergency
• High-risk pregnancy: Within five days of request or immediately if an emergency
• Postpartum: Between 21 and 56 days after delivery