Regulatory Guidelines & Appointment Availability Standards Reminder

Attention: Primary Care and Specialist Providers Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event.  TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event. Call to action: Texas Children’s Health Plan (TCHP) would like to remind network providers of the appointment availability standards and regulatory requirements. In 2015, Senate Bill 760 passed, requiring Texas Health and Human Services Commission (HHSC) to monitor the provider networks of managed care organizations. Texas Children’s Health Plan would like to ensure members are able to schedule appointments with providers in accordance with the HHSC’s appointment accessibility guidelines. How this impacts providers:  Texas Children’s Health Plan enforces access and other network standards required by the contract and takes appropriate action with providers whose performance is determined by the health plan to be out of compliance. In addition, providers and staff are responsible for understanding the requirements.    Provider Demographic Changes:  

• Demographic changes must be sent in writing.  
• TCHP is not responsible for potential claims processing and payment errors due to failure to update information.  
• Notification of change can be completed by accessing the form on the provider web page or portal at https://www.texaschildrenshealthplan.org/for-providers, once completed, fax to (832) 825-8750 or emailed to providerrelations@texaschildrens.org .  Here is the form you will need to complete: 

• Provider Information Form- to add a new provider or new location to your group.  
• Provider Information Change Form- to submit demographic changes, like the ones listed below. 

Network providers must also notify TMHP of any demographic changes. The form can be found here:http://www.tmhp.com/Provider_Forms/Provider%20Enrollment/F00114_Provider_Information_Change_Form.pdf AuthorizationsPrimary Care Providers, a reminder that a referral is not needed to see an in-network specialist.

APPOINTMENT AVAILABILITY STANDARDS  

PROVIDER TYPE	LEVEL/TYPE OF CARE	APPOINTMENT AVAILABILITY STANDARDS
OB/GYN	Emergency services    Urgent condition    Prenatal care for initial appointments    Prenatal care for initial appointments for high-risk pregnancies or new members in third trimester    Appointments for ongoing OB care must be available in accordance to treatment plan as developed by the provider	Immediately  Within 24 hours  14 days   Initial appointment must be offered within 5 days, or immediately, if emergency exists  Must be available in accordance to the treatment plan as developed by the provider
PRIMARY CARE PHYSICIANS	Emergency services    Urgent condition    Primary routine care    Preventive health services for Members 21 years of age or older   Preventive health services for members less than 6 months of age    Preventive health services for members 6 months through age 20    New members 20 years of age or younger to receive a Texas Health Steps checkup    CHIP Members should receive preventive care in accordance with AAP	Immediately  Must be provided within 24 hours Within 14 days  Within 90 calendar days   Offered as soon as possible but no later than 14 days of enrollment for newborns  Must be provided within 60 days     Within 90 days of enrollment   American Academy of Pediatrics(AAP)  Periodicity Schedule
SPECIALTY CARE	Emergency services    Urgent condition    Specialty routine care must be provided within 21 days	Immediately  Must be provided within 24 hours 21 days
BEHAVIORAL HEALTH	Emergency services    Urgent condition    Care for non-life threatening emergency - Behavioral Health    Initial visit for routine care - Behavioral Health    Follow-up routine care - Behavioral Health    Initial outpatient behavioral health visit (This does not apply to CHIP Perinate members)	Immediately  Within 24 hours  Within 6 hours*   Within 14 days*   Within 90 days*   Within 14 days

*Accessibility Standards set by National Committee for Quality Assurance Next steps for providers: Providers should share the appointment availability standards and regulatory guidelines with their staff and implement internal procedures for compliance, if needed.  If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org. For access to all provider alerts, log into:www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.