210 R.I. Code R. 210-RICR-30-05-2.15

Current through December 3, 2024

Section 210-RICR-30-05-2.15 - Service Accessibility Standards

A. The service accessibility standards which the health plan must meet are:

1. Twenty-four (24) hour coverage;

2. Travel time or distance;

3. Days to appointment for non-emergency services.

B. In addition, MCOs must staff both a member services and a provider services function.

1. Twenty-Four Hour Coverage - The MCO must provide coverage, either directly or through its PCPs, to members on a twenty-four (24) hours per day, seven (7) days a week basis. The MCO must also have available written policy and procedures describing how members and providers can contact it to receive instruction or prior authorization for treatment of an emergent or urgent medical problem.

2. Travel Time - The MCO must make available to every member a PCP whose office is located within twenty (20) minutes or twenty (20) miles driving time from the member's place of residence. Members may, at their discretion, select PCPs located farther from their homes.

3. Appointment for Non-Emergency Services - The MCO must make services available within twenty-four (24) hours and seven (7) days per week, including services for mental health and substance use disorders for treatment of an urgent medical problem. The MCO must make services available within thirty (30) days for treatment of a non-emergent, non-urgent medical problem. This thirty (30) day standard does not apply to appointments for routine physical examinations, nor for regularly scheduled visits to monitor a chronic medical condition if the schedule calls for visits less frequently than once every thirty (30) days. Non-emergent, non-urgent mental health or substance use appointments for diagnosis and treatment must be made available within ten (10) days.

4. Member Services - The MCO must staff a member services function operated at least during regular business hours and responsible for the following:

a. Orienting the member to the health plan and assisting members in the selection of a PCP;

b. Assisting members to make appointments and obtain services;

c. Assisting in arranging medically necessary transportation for members;

d. Arranging interpreter services;

e. Assisting in reporting fraud, waste, and abuse;

f. Assisting members with coordination of out-of-plan services;

g. Ordering member materials, such as handbooks and provider directories;

h. Explaining to members what to do in an emergency or urgent medical situation;

i. Assisting members with questions regarding benefits and how to access services;

j. Handling members' complaints, grievances, and appeals; and

k. Providing a toll-free telephone number.

C. The MCO must maintain a toll-free Member Services telephone number. Although the full Member Services function is not required to operate after regular business hours, this or another toll-free telephone number must be staffed twenty-four (24) hours per day to provide prior authorization of services during evenings and weekends, including pharmacy services.

D. Provider Services - The MCO must staff a provider Services function operated at least during regular business hours and responsible for the following:

1. Assisting providers with questions concerning member eligibility status and benefits;

2. Assisting providers with plan prior authorization, care coordination, network questions, and referral procedures;

3. Assisting providers with claims payment procedures;

4. Handling provider complaints.

210 R.I. Code R. 210-RICR-30-05-2.15

Amended effective 10/5/2021
Amended effective 12/12/2023
Amended effective 3/17/2024