InstructionsPROVIDER APPOINTMENT AVAILABILITY SURVEY RESULTS TEMPLATE - SPECIALISTVersion 2017 for Measurement Year 2017PLEASE first review the Provider Appointment Availability Survey Methodology and Instructions before completing this template. The data reported in this Form must reflect the Plan's contracted network of Specialist Physicians as of the date the Provider Contact List was generated for the reporting year. Calculate rates of compliance for each provider group in each county for each Survey Type and Product Type. All fields must be completed for each row, information in fields that do not change must be repeated in the row representing the variation. In some cases, the DMHC requires plans to use specific terminology or crosswalk the Plan's own terminology to the Department's preferred terms. These fields are identified within the Instructions below. The Plan may crosswalk its terminology utilizing the "Crosswalk" links within the Timely Access Reporting web portal under the Profile tab.

SURVEY RESULTS - SPECIALIST TABREQUIRED FIELDINSTRUCTIONSEnter data in each field as described below. If a certain field is not applicable, please enter "NA" unless such an entry is identified as not acceptable in the instructions. Please do not leave any required fields blank unless the instruction states a blank field is acceptable.Data Type (Length)Survey TypeEnter one of the following provider types: Cardiology, Endocrinology, Gastroenterology, Psychiatry, or Child and Adolescent Psychiatry.Text (1 to 25 characters)Name of Survey ToolSpecify the method the Plan used to obtain the timely access compliance data: Survey - Telephone Survey - Online/Email (See Option 3, Mental Health Addendum, PAAS Methodology) Clinic Data (See Option 1, Mental Health Addendum, PAAS Methodology)Text (1 to 25 characters)Commercial Product Enter "Y" or "N" to indicate whether the provider group participates in a commercial product. Please reference the PAAS for further instructions. If the plan has multiple products (e.g., commercial, individual, and/or Medi-Cal) and separate samples were surveyed for each product, please report the results for each product the provider group servers on separate rows. Enter "NA" for the product(s) that are accepted by the provider group, but are being reported on a separate row.Text (0 to 1 character)Individual/Family Plan Product Enter "Y" or "N" to indicate whether the provider group participates in an Individual/Family Plan product. Please reference the PAAS for further instructions. If the plan has multiple products (e.g., commercial, individual, and/or Medi-Cal) and separate samples were surveyed for each product, please report the results for each product the provider group servers on separate rows. Enter "NA" for the product(s) that are accepted by the provider group, but are being reported on a separate row.Text (0 to 1 character)Medi-Cal Product Enter "Y" or "N" to indicate whether the provider group participates in a Medi-Cal product. Please reference the PAAS for further instructions. If the plan has multiple products (e.g., commercial, individual, and/or Medi-Cal) and separate samples were surveyed for each product, please report the results for each product the provider group servers on separate rows. Enter "NA" for the product(s) that are accepted by the provider group, but are being reported on a separate row.Text (0 to 1 character)CountyCounty in the Plan's network that it surveyed.Text (1 to 50 characters)Provider Group/IPAName of provider group, IPA, or Federally Qualified Health Center (FQHC) affiliated with contracted provider (if applicable). If provider is not affiliated with a provider group, IPA, or FQHC, please enter the value "Individually Contracted Provider" as set forth in the Profile tab in the Timely Access portal. (Please make sure the provider group, IPA, or FQHC is referenced on the "Provider Groups/IPA Crosswalk" table in the Profile tab in the Timely Access Reporting web portal.)Text (1 to 100 characters)Number of Providers in Provider Group within Selected CountySpecify how many providers are set forth in the Plans de-duplicated Provider Contact List for each Survey Type in the Provider Group/County for the applicable Product Type. The Plan should use this number to determine its Target Sample Size. Please refer to the Provider Appointment Availability Survey (PAAS) Methodology for further instructions. Text (1 to 10 characters)Number of Providers RespondedIf the Plan is reporting survey results for a provider group or group of "Individually Contracted Providers," then include the total number of providers for each Survey Type within the group that responded to all applicable survey questions for the selected county. This number does not include the non-responding providers or ineligible providers. (See the PAAS Methodology for further information.)Text (1 to 10 characters)Target Survey Sample SizePlease record the target provider group sample size for the selected county, for each Survey Type, necessary to achieve a statistically reliable sample for the Provider Group/County, as determined by using the de-duplicated Provider Contact List and Appendix 1 of the PAAS Methodology. If the Plan elected to take a census of the provider group or group of Individually Contracted Providers, enter the number of providers set forth in the Plan's de-duplicated Provider Contact List for each Survey Type in the Provider Group/County. Please refer to the Provider Appointment Availability Survey (PAAS) Methodology for further instructions. Text (1 to 10 characters)Target Survey Sample Size AchievedPlease enter "Y" if the Plan sampled the provider group and was able to successfully survey the target sample size based on the "Target Survey Sample Size" and the "Number of Providers Responded". If the Plan conducted a census (i.e., surveyed all providers rather than sampling) or if the Plan initially pulled a sample but contacted all remaining providers in the group as replacements, enter "NA". If the Plan sampled the provider group, but was unable to meet the target sample size because it was unable to replace all non-responding or ineligible providers because it exhausted its "oversample" (and that oversample did not include all remaining providers in the group), then please enter "N." Even if unable to meet the Target Survey Sample Size, the plan must still report figures for each standard.Text (1 to 10 characters)Number of Non-Responding ProvidersRecord the number of providers, for each Survey Type in each PG/County, that did not respond to one or more survey items or declined to participate in the survey by calculating the number of providers identified in the "Rec Type" field of the Raw Data template as "Refused." (See the PAAS Methodology for further information.)Text (1 to 10 characters)Percentage of Non-Responding ProvidersUse the "Number of Non-Responding Providers" as the numerator. Add the "Number of Providers Responded" to the "Number of Non-Responding Providers" to calculate the denominator. Divide the numerator by the denominator. Multiple this number (e.g., .89) by 100 to calculate and report a percentage (e.g., 89%) in this field. (See the PAAS Methodology for further information on calculating and reporting a percentage of non-responding providers.)

(No. of Non-Responding Providers)-------------------------------------------------------------------------------------------- x 100 = (% Non-Responding Providers)(No. of Non-Responding Providers) + (No. of Providers Responded)Text (1 to 10 characters)Number of Providers that Responded to [specific standard]Specify the number of providers, for each Survey Type in each PG/County, that responded to that particular standard. Providers may decline to answer some parts of the survey as not being applicable to their practice. Do not count ineligible providers, non-responding providers or providers that responded that a particular appointment type was not applicable. If no providers within a group responded to a particular standard, enter "NA" (e.g., there were only two providers in a group and both were ineligible for the survey because they retired). This number should be used as the denominator to calculate the rate of compliance for each applicable standard. Text (1 to 10 characters)Number of Providers with an Appointment within [specific standard]Specify the number of providers that indicated an appointment was available within that particular standard. This number should be used as the numerator to calculate the rate of compliance for each applicable standard. Text (1 to 10 characters)Number of Providers who answered that Interpreter Services are Provided by [each response]Record the number of providers for each Survey Type in each PG/County who answered that interpreter services were provided by each response:

Telephone (e.g., Language Line.) Video-conference In-office Patient's friend or relative Other mechanism Interpreter services are not available I do not know

(See the PAAS Methodology for further information in reporting this information.)Text (1 to 10 characters)Percentage of Non-Responding ProvidersPlease verify the automatically calculated field is accuractly reflected based the numbers reported in the following fields: Use the "Number of Non-Responding Providers" as the numerator. Add the "Number of Providers Responded" to the "Number of Non-Responding Providers" to calculate the denominator. Divide the numerator by the denominator. Multiple this number (e.g., .89) by 100 to calculate and report a percentage (e.g., 89%) in this field. (See the PAAS Methodology for further information on calculating and reporting a percentage of non-responding providers.)

(No. of Non-Responding Providers)-------------------------------------------------------------------------------------------- x 100 = (% Non-Responding Providers)(No. of Non-Responding Providers) + (No. of Providers Responded)Text (1 to 10 characters)Rate of Compliance with [specific standard]Please verify the automatically calculated field is accuractly reflected based the numbers reported in the following fields: For each product (Commercial, IFP, Medi-Cal) for which the provider group is contracted, determine the total number of compliant providers for each standard using the responses from the raw data in the "Number of Providers with an Appointment within [specific standard]". The percentage should be reported for each Survey Type in each PG/County. Divide the "Number of Providers with an Appointment within [specific standard]" by the total "Number of Providers that Responded" for each product for each standard. Multiple this number (e.g., .89) by 100 to calculate a percentage (e.g., 89%). Report the rate of compliance for each product line as a percentage (e.g., 89%).

For example, if 100 providers responded for a specific standard, but only 80 providers are able to offer appointments within the standard, then the percent within standard would be 80%. If the Plan is reporting survey results for a county in which it contracts directly with individual providers, then include the percentage of responding providers that are able to offer appointments within the standard for the selected county. Please note that not all plans are required to fill in every category and a plan may indicate a field is not applicable by reporting "NA", as appropriate.

(Number of Providers with an Appointment within [specific standard])-------------------------------------------------------------------------------------------------- x 100 = (Rate of Compliance)(Number of Providers that Responded to [specific standard])

(See the PAAS Methodology for further information on reporting a rate of compliance for each Survey Type.) Text (1 to 10 characters)Percentage of Providers who answered that Interpreter Services are Provided by [each response]Please verify the automatically calculated field is accuractly reflected based the numbers reported in the following fields: Report a percentage for each Survey Type in each PG/County by dividing the "Number of Providers who answered that Interpreter Services are Provided by [each response]" (numerator) by the "Number of Providers Responded" (denominator). Multiple this number (e.g., .89) by 100 to calculate the percentage (e.g., 89%). If no providers responded, enter "NA" (e.g., there were only 2 providers in the group, both retired and were ineligible). A percentage should be reported for each of the following responses:

Telephone (e.g., Language Line.) Video-conference In-office Patient's friend or relative Other mechanism Interpreter services are not available I do not know

(Number of Providers who answered that Interpreter Services are Provided by [each response])---------------------------------------------------------- x 100 = (Percentage of Providers who answered (Number of Providers Responded) that Interpreter Services are Provided by [each response])

(See the PAAS Methodology for further information in reporting this information.)Text (1 to 10 characters)SUPPLEMENTAL SURVEY QUESTIONS TABPlan's Survey QuestionInclude each supplemental survey question that was included at the end of the PAAS and a summary of the responses. In addition, please summarize the results of the plan's supplemental questions by providing a numerator, denominator, and percentage. Text (1 to 100 characters)

Plan InformationPROVIDER APPOINTMENT AVAILABILITY SURVEYSurvey Method (please include a Word document with a more detailed description of methodology including specialties, sampling method, administration method, handling of non-respondents, etc. in TAR portal Section B.1 and a copy of the survey questions in Section B.1). Please indicate any variations to the Department's Survey Methodology in this section. Health Plan Name:Reporting Year:Name of Survey Vendor (If applicable):Date Contact List Generated:

Survey Results - SpecialistRow #Survey Type(Cardiology, Endocrinology, Gastroenterology, Psychiatry, or Child and Adolescent Psychiatry)Name of Survey Tool(Survey - Telephone, Survey - Online/Email, or Clinic Data)Commercial Product(s)(Y/N)Individual/Family Plan Product(s) (Y/N)Medi-Cal Product(s)(Y/N)CountyProvider Group/IPANumber of Providers in Provider Group within Selected CountyNumber of Providers RespondedTarget Survey Sample SizeTarget Survey Sample Size AchievedNumber of Non-Responding ProvidersNumber of Providers Responded to Urgent Care Appointment w/Prior Auth w/in 96 HoursNumber of Providers with an Urgent Care Appointment w/Prior Auth w/in 96 HoursNumber of Providers Responded to Non-Urgent Appointment w/in 15 DaysNumber of Providers with a Non-Urgent Appointment w/in 15 DaysNumber of Providers who answered that Interpreter Services are Provided by TelephoneNumber of Providers who answered that Interpreter Services are Provided by Video-ConferenceNumber of Providers who answered that Interpreter Services are Provided In-OfficeNumber of Providers who answered that Interpreter Services are Provided by Patient's Friend or RelativeNumber of Providers who answered that Interpreter Service by Other MechanismNumber of Providers who answered that Interpreter Services are Not Available Number of Providers who answered I do not know how Interpreter Services are providedPercentage of Non-Responding ProvidersRate of Compliance Urgent Care Appointment w/Prior Auth w/in 96 HoursRate of Compliance Non-Urgent Appointment w/in 15 daysPercentage of Providers who answered that Interpreter Services are Provided by TelephonePercentage of Providers who answered that Interpreter Services are Provided by Video-ConferencePercentage of Providers who answered that Interpreter Services are Provided In-OfficePercentage of Providers who answered that Interpreter Services are Provided by Patient's Friend or RelativePercentage of Providers who answered that Interpreter Services are Provided by Other MechanismPercentage of Providers who answered that Interpreter Services are Not Available Percentage of Providers who answered I do not know how Interpreter Services are provided0For DMHC use onlyFor DMHC use onlyFor DMHC use onlyFor DMHC use onlyFor DMHC use onlyFor DMHC use onlyFor DMHC use only000For DMHC use only0000000000000%0%0%0%0%0%0%0%0%0%0For DMHC use onlyFor DMHC use onlyFor DMHC use onlyFor DMHC use onlyFor DMHC use onlyFor DMHC use onlyFor DMHC use only000For DMHC use only0000000000000%0%0%0%0%0%0%0%0%0%0For DMHC use onlyFor DMHC use onlyFor DMHC use onlyFor DMHC use onlyFor DMHC use onlyFor DMHC use onlyFor DMHC use only000For DMHC use only0000000000000%0%0%0%0%0%0%0%0%0%0For DMHC use onlyFor DMHC use onlyFor DMHC use onlyFor DMHC use onlyFor DMHC use onlyFor DMHC use onlyFor DMHC use only000For DMHC use only0000000000000%0%0%0%0%0%0%0%0%0%0For DMHC use onlyFor DMHC use onlyFor DMHC use onlyFor DMHC use onlyFor DMHC use onlyFor DMHC use onlyFor DMHC use 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