Essential details on access to care surveys and our language assistance program

What you need to know:

• Care providers must participate in Provider Appointment Availability (PAAS) and After‑Hours surveys to ensure compliance with appointment availability standards.
• Access to care standards outline maximum waiting times for urgent and non‑urgent appointments, ensuring timely service availability.
• Language assistance services are offered to non‑English speakers, requiring care provider scheduling 3 days in advance for interpreters.

Each year, we conduct PAAS and After‑Hours surveys. These surveys are administered to selected network care providers. The PAAS survey helps measure if members can secure appointments within time frames mandated by the Department of Managed Health Care (DMHC) and California Department of Insurance (CDI). The After‑Hours survey measures care providers’ compliance with emergency and after‑hours service availability standards.

The 2025 surveys begin soon

The surveys are administered by our contracted vendor, Sutherland Healthcare Solutions. They will conduct both surveys from July 1, 2025, through December 31, 2025.

Understanding how to comply

Please review the appointment availability standards, as you may be contacted by Sutherland Healthcare Solutions for a survey.

• Compliant — The care provider offers an appointment within the required appointment timeframes.
• Non‑compliant — The care provider does not offer an appointment within any of the required time frames or refuses survey participation, leading to a corrective action plan by the health plan.
• The next available appointment date and time can be either in‑person or by telehealth services.

Please review and share the following Access Standards tables with your team.

Access standards for medical professionals and ancillary care providers

Access standards for behavioral health and employee assistance program (EAP) care providers

* The DMHC Timely Access standard is 15 business days for psychiatrists; however, we use the more stringent NCQA accreditation standard of 10 business days.

Access standards for after‑hours

Guidelines for clinical advice, interpreter services, and referrals

• Only appropriately qualified staff, such as a physician, physician’s assistant, nurse practitioner, or registered nurse, are allowed to provide triage or screening clinical advice.
• Interpreter services are coordinated by the health plan, its delegated network care provider, or other delegated entity with scheduled appointments for healthcare services in a manner that ensures the provision of interpreter services at the time of the appointment without imposing delay on the scheduling of the appointment. We require care providers and care provider office staff to document members’ requests, acceptance, or refusal of interpreter services in the medical record.
• Referrals to a specialist by a primary care provider or another specialist must meet applicable timely access standards.

The DMHC expanded the list of physicians and service‑type care providers in the PAAS. The list below identifies the care providers whose appointment availability must be assessed and reported.

Primary care providers:

• Primary care physicians
• Non‑physician medical practitioners providing primary care

Non-physician mental health care (NPMH) providers:

• Licensed clinical social worker
• Licensed marriage and family therapist
• Licensed professional clinical counselor
• Marriage and family therapist
• Master of Social Work
• Psychologist (PhD‑level)

Psychiatrists who practice in one or more of the following specialties or subspecialties:

• Psychiatry
• Additional psychiatry
• Child and adolescent psychiatry
• Geriatric psychiatry

Specialist physicians who practice in one or more of the following specialties or subspecialties:

• Cardiovascular disease and pediatric cardiology
• Dermatology and pediatric dermatology
• Endocrinology and pediatric endocrinology
• Epilepsy, neurology, and pediatric neurology
• Gastroenterology and pediatric gastroenterology
• Oncology and pediatric hematology/oncology
• Ophthalmology
• Otolaryngology and pediatric otolaryngology
• Pediatric pulmonology and pulmonology
• Urology and pediatric urology

Ancillary service providers that schedule appointments for the following services:

• Mammogram
• Physical therapy

Keeping you informed

To comply with the required timeframe standards, referrals to a specialist by a primary care or another specialist care provider should abide by the legislation introduced by SB221 Health care coverage: Timely Access to Care.

What happens if healthcare appointment standards are not met by care providers?

We are required by law to gather network appointment availability information from care providers to ensure members receive appointments within specific time frames. We are regulated by DMHC and CDI to monitor the care provider network for prompt access to care. If standards are not met or care providers refuse to participate in the surveys, corrective action may be initiated. In certain circumstances, time‑elapsed requirements may not be met, and we recognize the following exceptions:

Extending appointment wait time

The applicable waiting time for a particular appointment may be extended if the referring care provider or medical staff member 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. 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 availability standard may be met if the primary care provider offers an appointment to a patient within the same or the next business day from the appointment request.
Note: This exception does not apply to commercial Behavioral Health.

Resources:

• 24/7 NurseLine gives peace of mind: Members can access 24/7 NurseLine to get advice from a registered nurse anytime. The toll‑free phone number is listed on the back of the member ID card, and the wait time cannot exceed 30 minutes.
• Help is a phone call away: For general questions or needing help with referrals, please call the toll‑free phone number on the back of the member ID card to speak with the Member Services team. Representatives are available within 10 minutes during normal business hours.
• For patients with DMHC-regulated health plans: If you or your patients are unable to obtain a timely referral to an appropriate care provider or for more information about the regulations, visit the DMHC website at https://www.dmhc.ca.gov or call toll‑free 888‑466‑2219 for assistance.
• For patients with CDI‑regulated health plans: If you or your patients are unable to obtain a timely referral to an appropriate care provider or for more information about the regulations, visit the CDI website at https://www.insurance.ca.gov or call toll‑free 800‑927‑4357 for assistance.
• Language assistance program: For members whose primary language is not English, we offer a no-cost language assistance service through interpreters and other written languages. Care providers can contact Provider Services during business hours, and members can contact Member Services during business hours for language assistance services. For after-hours, they will need to contact the 24/7 NurseLine.
• Additionally, care providers need to request interpreters for face-to-face visits 3 business days ahead of time, with at least 24 hours for cancellations.

Questions

For general inquiries or assistance, visit the Contact Us page at https://www.anthem.com/ca/provider.

We hope this clarifies the expectations for timely access to care and the importance of survey participation. Our language assistance program is available to support you and enhance communication. Collaboration is key to effortlessly achieving compliance and minimizing member issues. Your participation as a valued network care provider is essential for success.