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CMS Health Plan Standards for Appointment Scheduling

Children’s Medical Services (CMS) Health Plan wants to ensure appointments for medical and behavioral health services are available to all our members on a timely basis. The following Appointment Availability standards can also be found in the Provider Manual (PDF). Please ensure these standards are implemented by your organization.

After Hours Passing Standards:

  • Answering service or system that can contact a physician. Member should receive a response within 30 minutes.
  • Advice nurse with access to physician.
  • Office telephone that transfers calls to a cell phone; or any method that ensures 24-hour phone access for members.

Provider Office Wait Times: 30 minutes maximum

  • Urgent Visit: Within 48 hours of the request for services that do not require prior authorization; within 96 hours of the request for services that do require prior authorization
  • Sick Visit: Seven calendar days
  • Routine Wellness Exam: 30 calendar days

  • Follow-Up After Physical Health Admission: Seven calendar days
  • Ancillary Services: 14 calendar days
  • Routine Prenatal Exam: Within 4 weeks until week 32; every two weeks until week 36; and every week after, up until delivery.
  • Routine Wellness Exam: 60 calendar days

  • Non-life-threatening emergency: six hours
  • Urgent Visit: Within 48 hours of the request for services that do not require prior authorization; within 96 hours of the request for services that do require prior authorization
  • Initial Visit for Routine Care: 14 calendar days
  • Follow-Up Routine Care: 30 calendar days
  • Follow-Up after Behavioral Health Hospital Admission: Seven calendar days (Scheduled prior to discharge)

Tip: Providers who meet standards based on telehealth or in-person appointments, are considered as “passing" when Secret Shopper exercises and audits occur.

Resources & Tips

Available 365 days a year.

Non-urgent sign language and language interpreter services.

Confidential, free, 24/7/365 support from a trained counselor for mental health, substance use or suicidal crisis.

Telehealth Offerings

Scheduling around a 4-day work week? Alternate between staff members. Providers are encouraged to utilize their own telehealth platforms, if available.

Virtual mental health services.

Pediatric clinicians available 24/7.

Virtual healthcare.