BOX B.2 Digital HMO Performance Standards
Objectives:
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To ensure that the HMO offers an acceptable level of provider and medical care access for Digital employees |
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In addition, the HMO must show a commitment to the development, maintenance, and improvement of efficient processes that effectively support member service activities. |
Proximity Requirements
Proximity Requirement/Two Primary Care Practitioners (PCPs)(Pediatrics): Members will have access to at least two available pediatric primary care practitioners (pediatric and/or family practice) within a 15-mile radius and/or 30 minutes in all zip codes in the HMO's service area. This standard may be adjusted in rural areas if appropriate.
Provider Access
The HMO will maintain the following provider-to-member ratios to ensure adequate provider access. These standards will be used as a guide and should report only those providers with practices that are open to new patients. Provider network and delivery system differences will be evaluated as needed.
Ratio for Internists/Family Practitioners: The ratio of internists/family practitioners to the enrolled population will not be less than 0 = 0.50:1,000.
Ratio for Pediatricians: The ratio of pediatricians to the enrolled population will not be less than 0 = .25:1,000.
Appointment Availability
The HMO will have a process in place to monitor PCP appointment availability for internal medicine/ family practice and pediatrics. In addition, the HMO will have a triage system which is available to members 24 hours a day. This triage system will have established guidelines for directing members to an appropriate level of care.
Nonsymptomatic Office Visits: Members requesting an office visit for nonsymptomatic related conditions will be seen within 30 calendar days. Examples of nonsymptomatic visits include well/ preventive care appointments for services such as annual physical examinations, annual gynecological examinations, and pediatric/adult immunizations.
Routine (Follow-up) Office Visits: Appointments will be available within 14 calendar days. Examples of routine appointments include follow-up appointments, blood pressure checks, and suture removal.
Nonurgent, Symptomatic Office Visits: Members requesting an office visit for nonurgent, symptomatic conditions will receive telephone triage including guided self-care the same day and the opportu
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