10.07.11.09

.09 Access and Availability of Services.

A. Regular Hours.

(1) With respect to all services it furnishes, whether direct or through contractual arrangements, an HMO shall provide for regular hours during which an enrollee may receive services.

(2) An HMO that provides services directly to its enrollees through its staff members shall have an orderly system for scheduling the provision of services to enrollees in a timely manner, taking into account the immediacy of need for services.

(3) An HMO that provides services to its enrollees through independent licensed health care providers under contract with the HMO shall ensure that the providers have an orderly system for scheduling the provision of services to enrollees in a timely manner, taking into account the immediacy of need for services.

B. Outside of Regular Hours. The HMO shall have a system for providing the enrollee with 24-hour access to a physician in cases where there is an immediate need for medical services. To meet this requirement, the HMO's arrangements for off-hour services may provide for access to physicians who do not have a contract with the HMO and facilities such as hospital emergency rooms. When a physician who does not have a contract with the HMO is used, the HMO shall develop and publicize procedures assuring that the HMO is notified of the services and receives adequate documentation from the physician or facility within a reasonable period of time.