CommercialMedicaidMarch 4, 2024
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:
- Providers must instruct their after-hours answering service to answer Anthem’s After Hours Survey questions. Non-compliant providers are subject to contractual enforcement actions, such as Corrective Action Plans (CAP) or escalated contractual sanctions for breach of contract.
- 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 healthcare 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 non-emergency 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
Note: The next available appointment date and time can be either in-person or by telehealth services.
Healthcare 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 business hours of request if authorization is not required or within 96 business hours of request if authorization is required, or as clinically indicated |
Routine primary care examination (non‑urgent) |
Within 10 business days of request |
Non-urgent consults/specialty referrals |
Within 15 business days of request |
Non-urgent care with non-physician mental health provider or substance use disorder (SUD) provider (where applicable) |
Within 10 business days of request |
Non-urgent follow-up care with non-physician mental health provider or SUD provider |
Within 10 business days of request |
Non-urgent ancillary |
Within 15 business days of request |
Mental health appointment, non-physician |
Within 10 business days of request |
SB221 — Effective since July 1, 2022, non-physician mental health/SUD appointments are subject to the timely access standards outlined in the chart above. This bill also requires that all health plans ensure that enrollees who are undergoing a course of treatment for an ongoing mental health or SUD condition can schedule a follow up appointment with their non-physicians mental healthcare or SUD provider within 10 business days of the prior appointment.
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 | |
First and second trimester |
Within seven days of request |
Third trimester |
Within three days of request |
High-risk pregnancy |
Within three days of identification |
Postpartum |
Between 7 and 84 days after delivery |
Long-term services and supports | |
Skilled nursing facility |
|
Intermediate care facility/developmentally disabled (ICF-DD) |
|
Community-based adult services (CBAS) |
Capacity cannot decrease in aggregate statewide below April 2021 level |
Specialists
The following guidelines are in place for our specialists:
- For urgent care, the specialist should see the member within 96 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 member during regular business hours — as well as after hours — for assistance and possible triage, the provider or another healthcare professional must either take the call or call the member back within 30 minutes of the initial call.
When an Anthem member arrives on time to an appointment, the member should be seen within 15 minutes of the scheduled appointment.
When Anthem members and/or prospective members call a physician’s office, they should not be placed on hold for longer than 10 minutes.
Interpretation services
When a provider’s office receives a call from an Anthem member, the provider’s office should know where to contact a telephone interpreter to communicate in the member’s preferred language.
Noncompliance
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, review the provider manuals at
https://providers.anthem.com/california-provider/resources/manuals-policies-guidelines.
Beginning in 2023, delegated network providers will be measured based on a compliance threshold of 70% as outlined in CCR 1300.67.2.2. Delegates scoring below 70% compliance for Non-Urgent and Urgent appointment availability will be subject to corrective action, up to and including, termination of the contract.
Required timely access training course — to be released in measurement year 2024
Rescheduling missed appointments — Los Angeles county providers only
Missed appointments |
Standard |
The time after a missed appointment that a patient is contacted to reschedule their appointment |
48 hours |
This is a reminder that Los Angeles county providers are required to call to reschedule an appointment within 48 hours after a missed appointment. Ensure your office’s policies and procedures and training are updated to include this requirement. Providers may be surveyed on a random sample to ensure compliance with this standard.
Schedule of timely access surveys
Provider Appointment Availability Survey (PAAS):
- Survey subject(s): Appointment availability
- Managed Care Plan: Anthem
- Contractor conducting survey: Sutherland
- Regulatory agency: Department of Managed Health Care (DMHC)
- Schedule: July through November 2024
After Hours and Appointment Availability Survey:
- Survey subject(s): Emergency and urgent after-hours calls
- Managed Care Plan: Anthem
- Contractor conducting survey: TBD
- Regulatory agency: National Committee for Quality Assurance (NCQA); DMHC
- Schedule: October through November 2024
Primary Care and Specialty Care Appointment Availability Survey:
- Survey subject(s): Appointment availability, interpretation services
- Conducting/regulatory agency: Department of Health Care Services (DHCS)
- Schedule:
- Q1: January through March
- Q2: April through June
- Q3: July through September
- Q4: October through December
DHCS administers the surveys, and Anthem is provided the surveys after each quarter.
Non-compliant providers are subject to contractual enforcement actions, such as Corrective Action Plans (CAP) or escalated contractual sanctions for breach of contract.
Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross, Anthem Blue Cross Life and Health Insurance Company, and Blue Cross of California Partnership Plan, Inc. are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County.
CABC-CDCM-050906-24, CABC-CDCM-060259-24, CABC-CDCM-070100-24
PUBLICATIONS: June 2024 Provider Newsletter, November 2024 Provider Newsletter
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