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:

Click on the attachment to view appointment access time requirements.

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.