TO: Participating Alabama Coordinated Health
Network (ACHN) Primary Care Physician (PCP) Groups
RE: 24/7 Voice-to-Voice Coverage Requirement for
ACHN PCP Groups
Primary Care Physician (PCP) groups
with an Alabama Coordinated Health Network (ACHN) agreement must comply with
the mandated 24 hours per day and seven (7) days per week (24/7) Voice-to-Voice
coverage. Per this mandate, all ACHN PCP groups are required to have
after-hours coverage. This allows patients to contact their PCP group to
receive instructions regarding care, at any time, so that care is provided in
the most appropriate manner relative to the patient’s condition. Additionally, Attachment A of the ACHN PCP
Group Enrollment Agreement and Chapter 40, Section 8.2 of the Alabama Medicaid
Provider Billing Manual, states that the PCP group must provide recipients with
after-hours instructions for care or referral at all times, for medical
conditions, 24 hours per day and 7 days per week as defined by ACHN Policy.
To meet the
24/7 requirement a PCP group can use one of the following methods:
- The
after-hours telephone number must connect the patient to the PCP group’s physician
or an authorized medical practitioner.
- The
after-hours telephone number must connect the recipient to a live voice
call center system or answering service that will either direct the
recipient to the appropriate care site or contact the PCP group’s physician
or PCP group’s authorized medical practitioner. If the PCP group’s physician
or authorized medical practitioner is contacted, then the recipient should
receive instructions within one (1) hour.
- The
after-hours telephone number can connect to a hospital if the PCP group has
standing orders with the hospital to direct recipients to the appropriate
care site. (For example, if the recipient’s symptoms are such that the
recipient can be seen the next morning, the hospital should direct the
recipient to contact the PCP group in the morning to make an appointment.) Hospital staff must be aware of
the 24/7 coverage protocol.
An office telephone line not answered after hours, or
answered after hours by a recorded message instructing the recipient to call
back during office hours or to go to the emergency department for care, is not
acceptable. It is also not acceptable to refer recipients to the PCP group’s home
telephone if there is not a system in place as outlined above to respond to
calls. In addition, systems designed to refer all requests to go to the
Emergency Room are not acceptable. Failure to comply with the 24/7 coverage
requirements may affect future participation opportunities. See Attachment A of
Alabama Medicaid Primary Care Physician Group Enrollment Agreement for more
information on the 24/7 Coverage Requirements.
As a reminder, the
after-hours coverage requirement will be monitored regularly. If during the
monitoring process a provider is not meeting the requirements as stated below,
the following may occur:
1. The group will be contacted in writing
and asked to submit, within 10 business days of receipt of the letter, a
corrective action plan (CAP) describing what steps will be taken to comply with
the requirement(s).
2. The group will receive a follow-up
monitoring call within 30 calendar days following submission of a CAP to
determine implementation of the CAP and continuing compliance. If after the
follow-up monitoring call the group is not maintaining compliance with the
requirement, the group will be notified in writing of the non-compliance status
and may be placed on suspension from the ACHN until further notice. Suspension
from participating with the ACHN will result in not receiving bonus payments and/or
ACHN participation rates. Notification of the suspension status will be forwarded
to the Agency’s Chief Medical Officer.
3. If the group fails to submit a CAP
within the allotted time, the group will be notified in writing of the
non-compliance status with the agreement and may be placed on suspension until
further notice. The group will be asked to submit a CAP within five (5)
business days of receipt of the letter. If the CAP is received in the allotted
time and approved, the group will be reinstated.
4. If the group fails to submit a CAP
after violation of item #3 within the allotted time the group will be notified
by certified mail of failure to comply with the after-hours coverage
requirements and, as a result, failed to comply with the Alabama Medicaid
Primary Care Physician Group Agreement and the agreement may be terminated.
If you have
questions about the 24/7 coverage policy and/or process, you may email ACHN@medicaid.alabama.gov.
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