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REQUIREMENTS: Appointment and Office Site Standards

Date: 04/17/23

As a reminder, Superior HealthPlan regularly conducts an assessment of practitioner accessibility and requires providers to maintain appointment availability and office site standards. This helps to ensure members have local access to diverse, qualified practices that are safe, accessible and available to provide quality care. Superior’s goal is to identify opportunities for improvement and eliminate any disparities. Standards are consistent with the National Committee for Quality Assurance (NCQA), Texas Department of Insurance (TDI) and Texas Health and Human Services (HHS) requirements.

Accessibility to health care is crucial in overall population health. When members are able to obtain quality health care in their area, they are more likely to adhere to treatment guidelines, maintain preventive health practices and receive services when needed the most. Superior maintains a diverse and geographically accessible health-care network by contracting with a wide range of providers, located in areas close to where members reside or work. Geographic accessibility is measured by how physically accessible services and resources are for members. Some factors that are taken into consideration when determining accessibility and developing Superior’s provider network, include:

  • Location
  • Geographic distribution of the population
  • Maximum coverage needed
  • Capacity of care for each practitioner
  • Environmental barriers
  • Available methods of transportation

HHS requires appointments for certain covered services be available during specified timeframes. Superior monitors appointment availability for routine primary care, specialty care and behavioral health visits annually. The annual audit includes timeframes for urgent care, emergency care and maximum wait times for scheduled and walk-in appointments. Providers must pass with 100% compliance. If compliance is not met, providers will be put on a Performance Improvement Plan. To review Appointment Availability Standards for Superior Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, STAR+PLUS Medicare-Medicaid Plan (MMP) and Wellcare By Allwell (HMO and HMO-DSNP) members, please download the Appointment Availability Standards, found under the Quality Resources section, on Superior’s Quality Improvement webpage.

Superior has also adopted guidelines for office sites and may conduct on-site visits at any time to ensure compliance. These visits may be initiated by an event or as an investigation of a complaint site, and may include evaluating a specific service or facility-related complaint. Any or all performance standards and thresholds may be reviewed during a complaint investigation.

Standards for office sites are measured utilizing guidelines in the following areas:

OFFICE SITE MEASURE

GUIDELINES

Physical Accessibility

  • Accessible entry and space within the building or practice site.
  • Ease of access for patients with physical disabilities.

Physical Appearance

  • Cleanliness of the building or practice site.
  • Proper and adequate lighting.
  • Safety concerns.

Adequacy of Waiting and Examination Room Space

  • Appropriate-sized space for patients in waiting and examination rooms.
  • Adequate amount of seating in waiting and examination rooms.

Adequacy of Medical/Treatment Record Keeping

  • Securely stored and out of plain sight documents/files containing protected health information.
  • Patient files documented timely, accurately and using the best practice.
  • Confidentiality and security protocols in place and being practiced.

For more information regarding geographical access standards, office site surveys or Superior’s adopted guidelines for office sites, please reference Superior’s Provider Trainings and Manuals or Provider Resources webpage.