Participate in our access to care surveys and Language Assistance Program

At a glance:

• Providers must participate in PAAS and After‑Hours Surveys to ensure compliance with appointment availability standards.
• Access to care standards outline maximum wait times for urgent and non‑urgent appointments, ensuring timely service availability.
• Language assistance services are offered to non‑English speakers, requiring provider scheduling three days in advance for interpreters.

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

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 providers

Access standards for Behavioral Health and Employee Assistance Programs (EAP) providers

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

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 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 a delay on the scheduling of the appointment. We require providers and 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 providers in the PAAS Survey. The table below identifies the list of the 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 (LPCC)
• 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 provide appointments to 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 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 providers?

We are required by law to gather network appointment availability information from our providers to ensure members receive appointments within specific time frames. We are regulated by the DMHC and CDI to monitor our provider network for prompt access to care. If standards are not met or 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 times: The applicable waiting time for a particular appointment may be extended if the referring 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 the recurrence of disease.

• Advanced access: The availability standard may be met if the 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.

We hope this information explains our expectations, your obligations, and offers support on compliance.

Resources

24/7 NurseLine

Members can access our 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.

For patients with DMHC‑regulated health plans

If you or your patients are unable to obtain a timely referral to an appropriate provider or for more information about the regulations, visit the DMHC website at https://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 provider or for more information about the regulations, visit the CDI website at http://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.

Providers can contact Provider Services during business hours and members can contact Member Services during business hours to language assistance services. For after hours, they will need to contact the 24/7 NurseLine.

Additionally, providers need to request interpreters for face‑to‑face visits 3 business days ahead of time with at least 24 hours for cancellations.

Questions

Availity Chat with Payer is available during normal business hours. Get answers to your questions about eligibility, benefits, authorizations, claims status, and more. To access Availity Essentials, go to https://Availity.com, log in, and select the appropriate payer space tile from the drop‑down. Then, select Chat with Payer and complete the pre‑chat form to start your chat.

For additional support, visit the Contact Us section of our provider website for the appropriate contact.

We hope this clarifies Anthem’s expectations and your obligations regarding compliance with timely access to care regulations and the importance of survey participation. Let us work together to meet the requirements with the least amount of difficulty and member abrasion. Achieving compliance is possible with your participation as our valued network provider.