State & FederalMedicaidJuly 1, 2020

Access to care standards

Participating providers are responsible for offering members access to covered services 24/7. Access includes regular office hours on weekdays and the availability of a provider or designated agent by telephone after regular office hours, on weekends and on holidays. When unavailable, providers must arrange for on-call coverage by another participating provider. Providers are also required to meet appointment access standards as described below.

 

After-hours calls:

  • The answering service or after-hours personnel must ask the member if the call is an emergency. In the event of an emergency, the member must be immediately directed to dial 911 or to proceed directly to the nearest hospital emergency room.
  • If staff or answering service is not immediately available, an answering machine may be used. The answering machine message must instruct members with emergency health care needs to dial 911 or go directly to the nearest hospital emergency room. The message must also give members an alternative contact number so they can reach the primary care physician (PCP) or on-call provider with medical concerns or questions.
  • Non-English-speaking members who call their PCP after hours should expect to get
    language-appropriate messages. In the event of an emergency, these messages should direct the member to dial 911 or proceed directly to the nearest hospital emergency room.

In a nonemergency situation, members should receive instruction on how to contact the on-call provider. If an answering service is used, the service should know where to contact a telephone interpreter. All calls taken by an answering service must be returned.

Appointment access

Health care providers must make appointments for members from the time of request as follows:

General appointment scheduling

Emergency examination

Immediate access, 24/7

Urgent (sick) examination

Within 48 hours of request if authorization is not required or within 96 hours of request if authorization is required, or as clinically indicated

Nonurgent (sick) examination

Within 48-72 hours of request or as clinically indicated

Routine primary care examination (nonurgent)

Within 10 business days of request

Nonurgent consults/specialty referrals

Within 15 business days of request

Nonurgent care with nonphysician mental health providers (where applicable)

Within 10 business days of request

Nonurgent ancillary

Within 15 business days of request

Mental health appointment, nonphysician

Within 10 business days of request

Services for members under the age of 21 years

Initial health assessments:

Children from birth to 20 years of  age

Within 120 days of enrollment

Preventive care visits

Within 14 days of request

Services for members 21 years of age and older

Initial health assessments

Within 120 days of enrollment

Preventive care visits

Within 14 days of request

Routine physicals

Within 30 days of request

Prenatal and postpartum visits

1st and 2nd trimester

Within 7 days of request

3rd trimester

Within 3 days of request

High-risk pregnancy

Within 3 days of identification

Postpartum

Between 21 and 56 days after delivery

Long-term services and supports

Skilled nursing facility

·         Rural and small counties — within 14 business days of request

·         Medium counties — within 7 business days of request

·         Small counties — within 5 business days of request

Intermediate care facility/developmentally disabled (ICF-DD)

·         Rural and small counties — within 14 business days of request

·         Medium counties — within 7 business days of request

·         Small counties — within 5 business days of request

Community-based adult services (CBAS)

Capacity cannot decrease in aggregate statewide below April 2012 level

       
Medical appointment standards (Los Angeles County only):

General appointment scheduling

Emergency examination

Immediate access, 24/7

Urgent (sick) examination

Within 24 hours of request

Nonurgent (sick) examination

Within 48 hours of request

Nonurgent routine examination

Within 10 days of request

Standing referral

Within 3 business days of request

Mental health appointment, nonphysician

Within 10 business days of request

Members under the age of 18 months

Initial health assessments

Within 120 days of  enrollment

Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services/child health and disability prevention (CHDP) or preventive care visits

Within 2 weeks of request

Services for members 18 months of age or older

Initial health assessments

Within 120 days of enrollment

EPSDT/CHDP or preventive care visits

Within 2 weeks of request

Routine physicals

Within 30 days of request

Prenatal and postpartum visits

First prenatal visit

Within 2 weeks of request

High-risk pregnancy

Within 3 days of identification

Postpartum

Between 21 and 56 days after delivery

Specialists

The following guidelines are in place for our specialists:

  • For urgent care, the specialist should see the member within 24 hours of receiving the request.
  • For routine care, the specialist should see the member within 15 business days of receiving the request.
  • A copy of the medical records and/or results of the visit should be sent to the PCP’s office to allow continuity of care.

 

Wait times

When a provider's office receives a call from an Anthem Blue Cross (Anthem) member during regular business hours for assistance and possible triage, the provider or another health care professional must either take the call or call the member back within 30 minutes of the initial call.

 

Noncompliance

Please ensure that you comply with the standards described; compliance with these standards is a contractual requirement. Anthem monitors compliance through a number of mechanisms, including annual telephonic surveys, to determine if participating provider offices meet the above standards. For additional details, please review the provider operations manual at https://mediproviders.anthem.com/ca/pages/manuals-training-more.aspx.

PUBLICATIONS: July 2020 Anthem Blue Cross Provider News - California