Priority Health works with providers to ensure that members have access to care 24 hours a day, 7 days a week.

Covering colleague(s)

Priority Health requires providers to name a colleague or colleagues who will be available to Priority Health members if the provider is unavailable for any time beyond the accessibility standards stated here.

Primary care standards

The following standards and measurement methodologies apply to primary care physicians and other primary care providers (PCPs) who provide medical services.

• They will be reported quarterly and annually.
• We communicate these standards to practitioners, measure performance against standards, and implement action toward improvements.
• Unless noted, the standards apply to treatment of members of all Priority Health plans.

Emergent care

Available immediately when appropriate and in all cases within 24 hours or less, 7 days per week, depending on the nature of the illness

Examples: Laceration, eye injury, musculoskeletal injury, exacerbation of asthma

Measurement methodology: Measurement includes all practitioners at the site visited. Emergency care is also assessed by member satisfaction surveys.

Urgent care

Available within two business days

Examples: High fever or persistent diarrhea and vomiting

Measurement methodology: Member satisfaction surveys and complaint monitoring 

Medicaid only: Measurement includes all practitioners at the site visited.

Symptomatic, non-urgent care

Available within 5 (Medicare) or 7 (Medicaid) business days

Examples: Upper respiratory infection, rashes, headaches & joint/muscle pain

Measurement methodology: Measurement includes all practitioners at the site visited. Symptomatic, non-urgent care is also assessed by member satisfaction surveys.

Routine care

Available within 30 business days (Medicaid 14 business days) for calls made to the office to schedule appointments

Examples: Follow-up appointments for blood pressure checks, diabetes, asthma

Measurement methodology: Member satisfaction surveys 

Medicaid only: Measurement includes all practitioners at the site visited. 

Preventive care/wellness exams

Available within 90 business days

Examples: Adult physical exams, well-child visits. Any medical concerns or symptomology expressed by the patient at the time they are scheduling a preventive care/wellness exam should be addressed according to standards 1-4 above.

Measurement methodology: Member satisfaction and complaint monitoring

Medicaid only: Measurement includes all practitioners at the site visited

Specialty care

Available within 6 weeks

Examples: Mole checks, allergy testing

Measurement methodology: Member satisfaction surveys

Acute specialty care

Available within 5 business days

Examples: Fracture or broken bones, lacerations, joint dislocation

Measurement methodology: Member satisfaction surveys

Prenatal care - initial prenatal appointment

This appointment should be with an obstetrician, primary care provider, certified nurse midwife or other advanced practice registered nurse with experience, training and demonstrated competence in prenatal care.

• If the member is in their first or second trimester: Within 7 business days of the member being identified as pregnant
• If the member is in their third trimester: Within 3 business days of the member being identified as pregnant
• If there's any indication of the pregnancy being high-risk (regardless of trimester): Within 3 business days of the member being identified as pregnant

After hours/24-hour accessibility

Available; phone calls are returned in 2 hours or less

Examples: Answering service, voice mail, answering machine and/or beeper availability

Measurement methodology: Assessed by member satisfaction surveys and complaint monitoring. See the after-hours coverage policy.

Return calls to members

During business hours in the same business day

Measurement methodology: Assessed by member satisfaction surveys conducted at least every year.