Accessibility to Care Standards

Highmark Wholecare has contracted with SPH Analytics, a National Committee for Quality Assurance (NCQA) certified vendor to conduct annual audits to assess our provider network’s ability to provide Highmark Wholecare members with timely access to care.
The audit addresses:
■ Appointment availability based on Highmark Wholecare standards
■ Access to care 24 hours a day/7 days a week
■ Wait time in the waiting room
■ Missed appointment protocol

The audit results are utilized to identify plan strengths and barriers to care, and provides Highmark Wholecare with the opportunity to develop initiatives to improve access.

Accessibility Audit

The Accessibility audit is conducted annually, typically in the 3rd Quarter of the year.
■ SPH Analytics will contact a random sample of our provider network by phone to complete the audit. Call-center agents will ask series of questions to determine compliance with Highmark Wholecare Accessibility Standards.
■ The call-center agent will request that the office appointment schedule be reviewed (real-time) to obtain a specific date and time of the office’s next available appointment.
■ Identification of office protocol or instructions provided to members by provider offices may also be included as part of the audit.

Important Audit Information

■ Providers are contractually obligated to participate in the audit.
■ Highmark Wholecare will announce the upcoming annual audit via fax blast and provider newsletter
■ Scheduling staff should be educated on the standards and aware of the audit time frame
■ The audit is conducted telephonically and will take 5 minutes to complete
■ Provider offices that are non-compliant with one or more standards will receive a report card identifying each non-compliant standard along with required actions

What you can do to prepare for the audit

■ Key office staff that schedule member appointments should review Highmark Wholecare’s Practitioner Accessibility Standards.
Important: Education of staff responding to the accessibility audit questions is a contributing factor to compliance with the standards.
■ Complete a Practice Self-Assessment to determine if your practice meets Highmark Wholecare’s Access to Care Standards.
Practice Self-Assessment Tool: The tool contains the accessibility standards monitored by Highmark Wholecare for both Medicaid and Medicare, the criteria a practice must meet to be compliant with the standards, and identifies questions that may be asked by call-center agents during an Accessibility Audit.