Access to Service Standards
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Defines timeframes and procedures for member access to emergency, urgent, primary, specialty, prenatal, preventive, and behavioral health services for Denver Health Medical Plan members, including after‑hours and nurse line availability.
No material clinical or coverage changes in this revision.
Access Standards and Timeframes
Access Standards
Access timeframes and member options:
ALL of the following
- Emergency Care — medical, behavioral, and substance abuse services available 24 hours a day, 7 days a week.
ALL of the following
- Urgent Care — medical, behavioral, and substance abuse services available within 24 hours.
ALL of the following
- Primary Care (routine, non-urgent symptoms) — appointment available within 7 calendar days.
- Primary Care after-hours access — office number answered 24 hours/day, 7 days/week by an answering service or instructions on how to reach a physician.
ALL of the following
- Behavioral Health (mental health and substance abuse; routine/non-urgent, non-emergency) — appointment available within 7 calendar days.
ALL of the following
- Prenatal Care — appointment available within 7 calendar days.
ALL of the following
- Preventive/Well Visits — appointment available within 30 calendar days.
ALL of the following
- Specialty Care (non-urgent) — appointment available within 30 calendar days.
- Network access alternative — if a specialty appointment is not available in-network within the timeframe, the member may be offered the option to see an out-of-network specialist or behavioral health practitioner.
ALL of the following
- Member support — Members may access the Nurse Line 24 hours a day, 7 days a week for health advice and immediate access to the provider on-call system.
Network Options and Provider Responsibilities
Network access alternative — offer out-of-network specialist when in‑network unavailable
If a specialty appointment is not available in-network within the required timeframe, offer the member the option to see an out-of-network specialist or behavioral health practitioner. Notify the member of this alternative and assist with arranging the out-of-network appointment when in-network access cannot be met within the specialty care timeframe (non-urgent: within 30 calendar days).
- Offer member the out-of-network option when in-network specialty care is not available within the timeframe.
- Assist with notification and scheduling of the out-of-network specialist or behavioral health practitioner as needed.
- Specialty care non-urgent access timeframe: within 30 calendar days.
Service Definitions and Access Descriptions
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