Access to Care Standards

When a member requests a primary or specialty care appointment, providers are required to follow Well Sense Health Plan’s Access to Care Guidelines regarding appointment availability wait times. Here are the standards:

After-Hours Services

Provide one of the following:

  • 24-hour answering service with option to page the physician, OR
  • Advice nurse with access to the PCP or on-call physician
Emergency and Psychiatric Services
  • Immediately upon entrance to delivery site, including network and out-of-network facilities
  • 24/7 services
Primary Care Services
  • Routine, non-symptomatic: 30 days
  • Non-urgent, symptomatic: 10 days
  • Urgent: 28 hours
Expectant Mothers
  • Non-symptomatic care: 30 days
  • Symptomatic care: 10 days
  • Urgent care: 48 hours
  • Initial prenatal visit: 21 days
  • Initial family planning visit: 10 days
Newborn Visit
  •  Within 14 calendar days of hospital discharge
Outpatient Specialty Services
  • Non-symptomatic care: 60 days
  • Non-urgent, symptomatic care: 30 days
  • Urgent care: 48 hours
Transitional Care

Primary, specialty or approved community mental health provider:

  • Within 2 calendar days following discharge
Transitional Home Care
  • Within 2 calendar days following discharge

Please see our Provider Manual or contact your dedicated Provider Relations Consultant for additional information.