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Office and Appointment Access Standards
Primary Care Manager’s Role

Office and Appointment Access Standards

One of the contract requirements for all network and MTF providers is to meet all office and appointment access standards. Those standards are as follows:
 
  • Emergency services must be available 24 hours a day, seven days a week.
  • Maximum wait times for appointment are:
     
    • One day for acute illness
    • One week for routine visits (health problems that are non-urgent)
    • Four weeks for wellness (preventive health) visits
    • Wait time for specialty care appointments will be based on the nature of the care required, but will not exceed four weeks (28 days). The primary care manager determines the level of urgency.
    • Office waiting times for nonemergency situations will not exceed 30 minutes.  Providers who are not able to adhere should notify the patient and offer to reschedule.
              
  • Patients calling after hours who are not suffering from conditions requiring emergency care should be offered the following guidance:
     
    • Put in contact with an on-call network physician covering for you or your practice
    • Offered self-care advice
    • Offered a next-day appointment when appropriate
    • Directed to an urgent care center that participates in the TRICARE program


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Primary Care Manager’s Role

TRICARE Prime beneficiaries agree to initially seek all nonemergency services from their PCM, a specified provider they selected for primary care services at the time of enrollment. The PCM is an individual provider within a military or civilian setting.

Note: Active duty service members (ADSMs) must always be referred for care outside of an MTF, including all behavioral health services, unless they have an assigned civilian PCM under TRICARE Prime or TRICARE Prime Remote.

The PCM’s roles and responsibilities include: 
  
  • Primary care services are typically, although not exclusively, provided by internal medicine physicians, family practitioners, pediatricians, general practitioners, and in some cases, obstetricians/gynecologists.
  • When a provider signs a contractual agreement to become a PCM, the provider must follow TRICARE procedures and requirements for obtaining specialty referrals and prior authorizations for nonemergency inpatient and certain outpatient services.
  • In the event the PCM assigned cannot provide the full range of primary care functions necessary, the PCM must ensure access to the necessary health care services, as well as any specialty requirements.
  • PCMs are required to provide access to care 24 hours a day, seven days a week, including after hours and urgent care services, or arrange for “On Call” coverage by another provider.  Note: The “On Call” provider must be certified and preferably should be a network provider who is also credentialed.
The PCM or “On Call” provider will determine the level of care needed:
 
  • Routine care—The PCM instructs the TRICARE Prime beneficiary to contact the PCM’s office on the next business day for an appointment.
  • Urgent care—The PCM or “On Call” provider coordinates timely care for the TRICARE Prime beneficiary.
  • The “On Call” physician should contact the PCM within 24 hours of an inpatient admission to ensure continuity of care.
  • PCMs referring patients for specialty care may need to coordinate the referral with Humana Military.


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Last Update: July, 2007