Harvard Pilgrim’s Access to Care Standards

One of Harvard Pilgrim’s fundamental priorities is ensuring the best possible access to care for the members we serve. To that end, Harvard Pilgrim maintains Commercial and StrideSM (HMO) Medicare Advantage policies that outline network practitioner standards regarding clinician availability, timeliness of appointments, and telephone accessibility, among other things.

Commercial Practice Site Standards Policy

The Practice Site Standards highlights specific standards in a variety of areas from telephone accessibility to standards for the office, waiting room, and exam rooms. Access to care guidelines include, but are not limited to:

  • In general, PCPs should not keep members with a scheduled appointment waiting an unreasonable length of time
  • Acceptable telephone coverage available after primary care office hours and reasonable time between pick up and connection
  • Emergency coverage available on a 24-hour basis for all covered services
  • Urgent appointments within 24 hours
  • Non-urgent appointment timeframes vary with state guidelines for MA, ME, and NH. Typically, PCPs’ symptomatic or medically necessary office visits should be available within 7 days.
  • For specialty adult and pediatric providers, initial non-urgent visits should be available within 14 days and urgent visits for most states within 7 days (24 hours for ME)

Medicare Advantage Access to Care Standards

Likewise, the Medicare Advantage Access to Care policy outlines standards and requirements for Harvard Pilgrim network providers regarding accessibility and timeliness of care provided.

The Centers for Medicare and Medicaid Services (CMS) requires that practitioners maintain convenient hours of operation and non-discriminatory access to services. To that end, the policy indicates that practitioners must provide coverage for their practice 24 hours a day, seven days a week with a published after-hours telephone number, pager or answering service, or a recorded message directing members to a provider for after-hours care instruction.

Other access to care requirements include, but are not limited to, the following:

  • Preventive care appointment or immunization: within 90 days of a member’s request
  • Scheduled appointments: within 30 minutes of member’s arrival
  • Routine/well care appointment: within one month of a member’s request
  • Urgent appointment: within 48 hours of a member’s request
  • Telephone responsiveness: Providers should give a timely response to incoming phone calls. Providers should answer calls in six rings or less and limit hold time to two minutes or less.

In addition, all services must be accessible to all members — including those with limited English proficiency or reading skills and those with diverse cultural and ethnic backgrounds — and provided in a culturally competent manner. For complete information, please refer to our Commercial Practice Site Standards and Medicare Advantage Access To Care policies.


Audrey Kleinberg,
Director, Provider Relations & Communications

Annmarie Dadoly,
Senior Manager, Provider Communications

Joseph O’Riordan,
Editor

Kristin Edmonston,
Production Coordinator