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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