Triage System Sample Clauses
The Triage System clause establishes a structured process for prioritizing and addressing issues, requests, or incidents based on their urgency and impact. In practice, this clause typically outlines criteria for categorizing matters into different levels of priority, such as critical, high, medium, or low, and may specify response times or escalation procedures for each category. Its core function is to ensure that the most pressing concerns are handled promptly and efficiently, thereby improving workflow management and minimizing the risk of unresolved critical issues.
Triage System. The Contractor must maintain a triage system for the management of Emergency Conditions and Urgent Care. The triage system, including the identification of the appropriate level of care, must be driven by clinically based criteria consistent with clinical research and industry standards. The clinical criteria must include protocols about the processes for access to, and communication with, appropriate PCPs or PCTs and the Enrollee’s other Providers.
Triage System. The Contractor must maintain a triage system for the management of Emergency Conditions and Urgent Care. The triage system, including the identification of the appropriate level of care, must be driven by clinically based criteria consistent with clinical research and industry standards. The clinical criteria must include protocols about the processes for access to, and communication with, appropriate PCPs or PCTs and the Enrollee’s other Providers.
3. Access to Services for Emergency Conditions and Urgent Care The Contractor must ensure access to 24-hour emergency services for all Enrollees, whether they reside in institutions or in the community.
a. When service for an Emergency Condition is required, the Contractor must have a process established to notify the PCP or PCT (or the designated covering physician) within one business day after the Contractor is notified by the Provider. If the Contractor is not notified by the Provider within 10 calendar days of the Enrollee’s presentation for emergency services, the Contractor is not responsible for payments;
b. When Urgent Care is required, the Contractor must have a process to notify the PCP or PCT within 24 hours after the Contractor is notified;
c. Summary information about Emergency Conditions and Urgent Care services provided must be recorded in the Centralized Enrollee Record no more than 18 hours after the PCP or PCT is notified, and a full report of the services provided within two business days;
d. If services are obtained out of network for Emergency Conditions, the Contractor must pay the Provider or reimburse the Enrollee, in the fee-for- service amount that would have been paid by Medicare or MassHealth, within 60 calendar days after the claim has been submitted; and
e. The Contractor must cover and pay for any services obtained for Emergency Conditions in accordance with 42 CFR 438.114(c) and Mass. Gen. Laws c. 118E, §17A.
4. Urgent Care and Symptomatic Office Visits All Urgent Care and symptomatic office visits must be available to Enrollees within 48 hours. A symptomatic office visit is an encounter associated with the presentation of medical symptoms or signs, but not requiring immediate attention. Examples include recurrent headaches or fatigue.