The annual Provider Appointment Availability Survey (PAAS) is currently in progress.  It is very important that you review this information with your office staff, so they are prepared and understand each provider’s responsibility to participate in the surveys. 

Here is what you need to do:  Educate your staff on the standards for appointment scheduling and after-hours care.

 

Access Standards for Medical Professionals

Type of Care

Standard

Non-urgent appointments for Primary Care (PCP)

Must offer the appointment within 10 business days of the request

Urgent Care appointments not requiring prior authorization

Must offer the appointment within 48 hours of request

Non-urgent appointments with Specialist Physicians

Must offer the appointment within 15 business days of the request

Urgent Care (that requires prior authorization)

Must offer the appointment within 96 hours of request

Non-urgent appointment for ancillary services (for diagnosis or treatment of injury, illness, or other health condition)

Must offer the appointment within 15 business days of the request

After Hours Care

Member to reach a recorded message or live voice response providing emergency instructions; and for non-emergent (urgent) matters, information when to expect to receive a call back

Emergency Care:  Anthem Blue Cross expects every practitioner to instruct their after-hours answering service staff that if the caller is experiencing an emergency, the caller should be instructed to dial 911 or to go directly to the emergency room.  Answering machine instructions must also direct the member to call 911 or go to the emergency room if the caller is experiencing an emergency.

Immediate Access to Emergency Care.

Members are directed to dial 911 or go to the nearest emergency room

Member Services by Telephone:  Access to Member Services to obtain information about how to access clinical care and how to resolve problems.  (This is a Plan responsibility and not a physician responsibility; and this also applies to our Behavioral Health members.)

Reach a live person within 10 minutes during normal business hours (Plan standard: 45 seconds; Call abandonment rate <5%). The Member NurseLine is available 24/7 and the wait time is not to exceed 30 minutes.

 

Note: The next available appointment date and time can be either In-Person or by Telehealth.

 

For questions, please visit the Contact Us page on our provider website for up-to-date contact information.  Simply click on the link below and select the CA Contract Support - Provider Experience representative for your county. https://www.anthem.com/ca/provider/contact-us/

 

Access Standards for Behavioral Health and EAP Providers

 

Type of Care

Standard

Emergency Care Instructions

(Anthem Blue Cross expects every practitioner to instruct their after-hours answering service staff that if the caller is experiencing an emergency, the caller should be instructed to dial 911 or to go directly to the emergency room. Answering machine instructions must also direct the member to call 911 or go the emergency room if the caller is

 

experiencing an emergency) Members are directed to 911 or the nearest emergency room.

 

Members are directed to 911 or the nearest emergency room.

 Non-Life-Threatening Emergency Care

Appointment within 6 hours

Members are directed to 911 or the nearest emergency room.

Urgent Care (does not require prior authorization)

Appointment within 48 hours

Members are directed to 911 or the nearest emergency room.

Urgent Care (requires prior authorization)

Appointment within 96 hours

Members are directed to 911 or the nearest emergency room.

Routine Office Visit/Non-urgent Appointment

10 business days (Psychiatrists)*

10 business days (Non-Physician Mental Health Care Providers)

5 business days (EAP)

Access to After-hours Care

Available 24 hours/7 days. Member to reach a recorded message or live voice response providing emergency care instructions, and for non-emergent (urgent) matters, a mechanism to reach a Behavioral Health/EAP provider and be informed when the call will be returned.


* The DMHC Timely Access standard is 15 Business days for Psychiatrists; however, to comply with the NCQA accreditation standard of 10 Business Days, Anthem uses the more stringent standard.

 

Note:  The next available appointment date and time can be either in-person or by telehealth services.

 

Email any questions to Behavioral Health Provider Experience at CABHNetworkRelations@anthem.com.

 

WHY IS THIS IMPORTANT:   These are California state regulations.

 

Blue Cross of California dba Anthem Blue Cross and Anthem Blue Cross Life & Health Insurance Company (collectively, Anthem”) are committed to keeping you, our network partners, updated on our activities related to our compliance with the Department of Managed Health Care (DMHC) and the California Department of Insurance (CDI) Timely Access to Non-Emergency Health Care Services Regulations (the “Timely Access Regulations”), respectively. 

 

To ensure compliance with these Timely Access Regulations, three (3) surveys are conducted annually.  These activities include, but are not limited to the following:

 

  • Provider Appointment Availability Survey
  • Provider Satisfaction Survey
  • Provider After – Hours Survey


Each year we communicate Anthem’s Timely Access Regulations and Language Assistance Program to our commercial Medical and Behavioral Health networks.  The 2021 notice was mailed in February.  This information also includes access to non-emergency health care services within prescribed timeframes (also referred to as the “time elapsed standards” or “appointment wait times”). We appreciate that in certain circumstances time-elapsed requirements may not be met. The Timely Access Regulations have provided exceptions to the time-elapsed standards to address these situations:

 

Extending Appointment Wait Time: The applicable waiting time for a particular appointment may be extended if the referring or treating licensed health care provider, or the health professional providing triage or screening services, as applicable, acting within the scope of his or her practice and consistent with professionally recognized standards of practice, has determined and noted in the relevant record that a longer waiting time will not have a detrimental impact on the health of the patient.

Preventive Care Services and Periodic Follow-up Care: Preventive care services and periodic follow up care are not subject to the appointment availability standards. These services may be scheduled in advance consistent with professionally recognized standards of practice as determined by the treating licensed health care provider acting within the scope of his or her practice. Periodic follow-up care includes but is not limited to, standing referrals to specialists for chronic conditions, periodic office visits to monitor and treat pregnancy, cardiac or mental health conditions, and laboratory and radiological monitoring for recurrence of disease.

Advanced Access: The primary care appointment availability standard may be met if the primary care physician office provides “advanced access.” “Advanced access” means offering an appointment to a patient with a primary care physician (or nurse practitioner or physician’s assistant) within the same or next business day from the time an appointment is requested (or a later date if the patient prefers not to accept the appointment offered within the same or next business day). Note: This exception does not apply to commercial Behavioral Health.


24/7 NurseLine Gives Peace of Mind

Anthem members have access to our 24/7 NurseLine. A convenient way to ask questions or get advice from a registered nurse anytime. Locate the toll-free phone number on the back of the Member ID card and the wait time is not to exceed 30 minutes.  

Help is a Phone Call Away

Members and Providers have access to Anthem’s Member Services team for general questions or when having difficulty obtaining a referral to a provider. Call the toll-free phone number listed on the back of the member ID card for assistance. A representative may be reached within 10 minutes during normal business hours.

 

For patients (members) with DMHC regulated health plans

If you or your patients are unable to obtain a timely referral to an appropriate provider or for more information about the regulations, visit the DMHC website at www.dmhc.ca.gov/HealthCareinCalifornia/YourHealthCareRights/TimelyAccesstoCare.aspx or call toll-free 888-466-2219 for assistance.

 

For patients (members) with CDI regulated health plans

If you or your patients are unable to obtain a timely referral to an appropriate provider or for more information about the regulations, visit the CDI website at www.insurance.ca.gov or call toll-free 800-927-4357 for assistance.

 

Language Assistance Program

For members whose primary language is not English, Anthem offers, at no cost, language assistance services through interpreters and other written languages. If you or the member is interested in these services, please call the Anthem Member Services number on the member’s ID card for help (TTY/TDD: 711).

 

We hope this clarifies Anthem’s expectations and your obligations regarding compliance with the Timely Access Regulations. Our goal is to work with you, to successfully meet the expectations for the requirements with the least amount of difficulty and member abrasion. Anthem can only achieve this compliance with the help of our network providers, you! 

1289-0921-PN-CA



Featured In:
September 2021 Anthem Blue Cross Provider News - California