AdministrativeCommercialDecember 1, 2023

Contract compliance with accessibility standards for Appointment Availability and Emergency Care instructions After Hours Care

Anthem Blue Cross (Anthem) monitors member access to a provider’s care through several mechanisms, including provider and member surveys. These surveys are conducted by Anthem and external entities such as Sutherland Healthcare Solutions, North American Testing Organization (NATO), and the Consumer Assessment of Healthcare Providers and Systems® (CAHPS) program.

Surveys give insight:

  • In surveying compliance with After Hours standards, participating providers’ offices are called outside of normal business hours to determine if callers are given appropriate emergency instructions and have a mechanism to reach a provider after regular hours for urgent situations.
  • In surveying compliance with Appointment Availability standards, participating providers’ offices are called within normal business hours and are asked when the next available appointment for urgent and non-urgent care would be.
  • Members are also surveyed via mail. The surveys, in addition to monitoring member complaints, help us to identify whether access to care is available to our members after or before normal business hours.

The key to our 2023 success is you:

If you have already taken steps to comply with the standards — Thank you! This year’s surveys are now under way, and with your continued support and commitment, we can achieve the best results possible for 2023.

Take a minute to review the 2022 survey results in the table below. We hope sharing them with you provides a better understanding of how you can help improve 2023 results.

Provider After Hours results — 2022 survey:

Question

Threshold > 85% of providers comply with the standard

Result

(% compliant with standard)

“What would you tell a caller who states he/she is dealing with a
life-threatening emergency?”

Compliant answers: Hang up and dial 911 or go to the nearest emergency room; go to nearest emergency room; or hang up and dial 911.

Medical:

Behavioral health:

89.0%

77.1%

Urgent Request After Hours: “In what time frame can the patient expect to hear from the provider or on-call provider?”

Note: Providers are expected to give a specific timeframe in which a member can expect a return call. If a specific timeframe is not provided, the answer is considered “non-compliant.”

Medical:

Behavioral health:

80.2%

41.3%


Provider Appointment Availability Survey (PAAS) Results — 2022 survey

Question

Threshold > 85% of providers comply with the standard

Result

(% compliant with standard)

“When is the next available appointment time for an urgent appointment?

Compliant answer: Appointment available within 48 hours (PCP), or within 96 hours (specialist)

Primary care Physician:

Specialist Physician:

Behavioral health:

Ancillary:

53%

48%

61%

N/A

“When is the next available appointment time for a non-urgent appointment?”

Compliant answer: Appointment available within 10 business days (PCP) or within 15 business days (Specialist)

Primary care Physician:

Specialist Physician:

Behavioral health:

Ancillary:

74%

54%

84%

90%

You make a difference:

  • Review the Commercial Access Standards under the Legaland Administrative Requirements section in your Anthem Blue Cross California Facility and Professional Provider Manual. Make sure your practice policy and procedures comply with the standards.
  • Ensure your After-Hours office staff, answering service or answering machine message specifically informs callers when their urgent (non-emergent) calls will be returned.
  • Ensure your After-Hours office staff, answering service or answering machine message directs callers to dial 911 or go to the nearest emergency room if they are experiencing an emergency.
  • Ensure that your office staff are aware of and able to comply with the appointment availability standards when setting appointments for our members.

If your office was surveyed in 2022 and found non-compliant with these standards, a letter with recommended compliance measures was sent to an active mailing address on file for you.

If you have questions, email our Healthcare Networks team for assistance from our Contact Us webpage. Under the section Additional support, select the link send us a message to open an email form. Make sure to enter the words, “2022 Survey After Hours and PAAS Results” in the subject field. Visit us online to view other contact options.

CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

CABC-CM-044280-23

PUBLICATIONS: December 2023 Provider Newsletter