Rhode Island Code of Regulations
Title 210 - Executive Office of Health and Human Services
Chapter 30 - Medicaid for Children, Families, and Affordable Care Act (ACA) Adults
Subchapter 05 - Service Delivery Options
Part 2 - Medicaid Managed Care Delivery Options
Section 210-RICR-30-05-2.15 - Service Accessibility Standards
Universal Citation: 210 RI Code of Rules 30 05 2.15
Current through March 25, 2025
A. The service accessibility standards which the health plan must meet are:
1. Twenty-four (24) hour coverage;
2. Travel time or distance;
3. Days to appointment for non-emergency
services.
B. In addition, MCOs must staff both a member services and a provider services function.
1. Twenty-Four Hour Coverage - The
MCO must provide coverage, either directly or through its PCPs, to members on a
twenty-four (24) hours per day, seven (7) days a week basis. The MCO must also
have available written policy and procedures describing how members and
providers can contact it to receive instruction or prior authorization for
treatment of an emergent or urgent medical problem.
2. Travel Time - The MCO must make available
to every member a PCP whose office is located within twenty (20) minutes or
twenty (20) miles driving time from the member's place of residence. Members
may, at their discretion, select PCPs located farther from their
homes.
3. Appointment for
Non-Emergency Services - The MCO must make services available within
twenty-four (24) hours and seven (7) days per week, including services for
mental health and substance use disorders for treatment of an urgent medical
problem. The MCO must make services available within thirty (30) days for
treatment of a non-emergent, non-urgent medical problem. This thirty (30) day
standard does not apply to appointments for routine physical examinations, nor
for regularly scheduled visits to monitor a chronic medical condition if the
schedule calls for visits less frequently than once every thirty (30) days.
Non-emergent, non-urgent mental health or substance use appointments for
diagnosis and treatment must be made available within ten (10) days.
4. Member Services - The MCO must staff a
member services function operated at least during regular business hours and
responsible for the following:
a. Orienting
the member to the health plan and assisting members in the selection of a
PCP;
b. Assisting members to make
appointments and obtain services;
c. Assisting in arranging medically necessary
transportation for members;
d.
Arranging interpreter services;
e.
Assisting in reporting fraud, waste, and abuse;
f. Assisting members with coordination of
out-of-plan services;
g. Ordering
member materials, such as handbooks and provider directories;
h. Explaining to members what to do in an
emergency or urgent medical situation;
i. Assisting members with questions regarding
benefits and how to access services;
j. Handling members' complaints, grievances,
and appeals; and
k. Providing a
toll-free telephone number.
C. The MCO must maintain a toll-free Member Services telephone number. Although the full Member Services function is not required to operate after regular business hours, this or another toll-free telephone number must be staffed twenty-four (24) hours per day to provide prior authorization of services during evenings and weekends, including pharmacy services.
D. Provider Services - The MCO must staff a provider Services function operated at least during regular business hours and responsible for the following:
1. Assisting providers with questions
concerning member eligibility status and benefits;
2. Assisting providers with plan prior
authorization, care coordination, network questions, and referral
procedures;
3. Assisting providers
with claims payment procedures;
4.
Handling provider complaints.
Disclaimer: These regulations may not be the most recent version. Rhode Island may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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