Date: May 8, 2023
Attention: Primary Care and Specialist Providers
Launch timeframe: Summer 2023
Call to action: Texas Children’s Health Plan (TCHP) is excited to launch our annual Provider Appointment Accessibility this summer- this time with a new feature. Providers that complete the survey will be entered into a gift card drawing*. Winning practices will be contacted at the conclusion of the survey.
Background information: In 2015, Senate Bill 760 passed, requiring Texas Health and Human Services Commission (HHSC) to monitor the provider networks of managed care organizations. TCHP would like to ensure members are able to schedule appointments with providers in accordance with the HHSC’s appointment accessibility guidelines. To accomplish this, we have partnered with SPH Analytics to conduct an appointment accessibility survey during this summer to verify that network providers meet the required standards.
How this impacts providers: TCHP 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.
*Please note, not all provider offices are surveyed. It is a random sample chosen by SPH Analytics.
Authorization reminder: Primary 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 | Immediately |
| Urgent condition | Within 24 hours | |
| Initial appointment for prenatal care | 14 days | |
| Initial prenatal care appointments for high-risk pregnancies or new members in third trimester (≥24 weeks) | Initial appointment must be offered within 5 days, or immediately, if emergency exists | |
| Appointments for ongoing OB care must be available in accordance to treatment plan as developed by the provider | Must be available in accordance to the treatment plan as developed by the provider | |
| PRIMARY CARE | Emergency services | Immediately |
| PHYSICIANS | Urgent condition | Must be provided within 24 hours |
| Primary routine care | Within 14 days | |
| Preventive health services for Members 21 years of age or older | Within 90 calendar days | |
| Preventive health services for members less than 6 months of age | Offered as soon as possible but no later than 14 days of enrollment for newborns | |
| Preventive health services for members 6 months through age 20 | Must be provided within 60 days | |
| New members 20 years of age or younger to receive a Texas Health Steps checkup | Within 90 days of enrollment | |
| CHIP Members should receive preventive care in accordance with American Academy of Pediatrics (AAP) | AAP Periodicity Schedule | |
| SPECIALTY CARE | Emergency services | Immediately |
| Urgent condition | Must be provided within 24 hours | |
| Specialty routine care | 21 days | |
| BEHAVIORAL | Emergency services | Immediately |
| HEALTH | Urgent condition | Within 24 hours |
| Care for non-life threatening emergency | Within 6 hours* | |
| Initial visit for routine care | Within 14 days* | |
| Follow-up routine care | Within 90 days* | |
| Initial outpatient behavioral health visit (Does not apply to CHIP Perinate members) | Within 14 days | |
| Initial outpatient treatment after inpatient discharge | Within seven (7) days from the date of discharge* |
*For more information on behavioral health guidelines see the provider alert, http://www.thecheckup.org/2021/02/12/provider-alert-attention-behavioral-health-providers-and-inpatient-facilities/.
Next steps for providers: Providers should share the appointment availability standards 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.