Participate in our access to care surveys and use our language assistance program

2024 surveys

Each year, Anthem and other health plans in California conduct provider appointment availability (PAAS) and after-hours surveys. These surveys are administered to randomly selected network providers. The PAAS survey helps measure if members can secure appointments within the timeframes mandated by the Department of Managed Health Care (DMHC) and the California Department of Insurance (CDI). The after-hours survey measures providers’ compliance with emergency and after-hours service availability standards.

The 2024 PAAS, currently in process, is administered by Anthem’s contracted vendor, Sutherland Healthcare Solutions. They will conduct the 2024 PAAS and after-hours surveys from July 1 through December 31, 2024.

Understanding how to comply

If Sutherland Healthcare Solutions contacts your office (via fax, email, or telephone) for a survey about urgent and non-urgent appointment availability, refer to the charts that follow for specific standards:

• Compliant — The provider offers an appointment within the required appointment timeframes.
• Non-compliant — The provider fails to offer an appointment within any of the required timeframes or refuses survey participation, leading to a Corrective Action Plan by Anthem.
• 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 that follow with your team.

Access standards for medical professionals and ancillary providers

Access standards for behavioral health and 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, Anthem uses the more stringent standard.

Access standards for after-hours

• Only appropriately qualified staff such as a physician, physician assistant, nurse practitioner, or registered nurse may provide triage or screening clinical advice.
• Interpreter services are coordinated by Anthem or 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 in scheduling the appointment. Anthem requires providers and provider office staff to document members’ request, 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.

In 2023 DMHC expanded the list of physicians and service type providers in the PAAS. The table below identifies an updated list of these providers.

Keeping you informed

SB 221 introduced new legislation beginning January 1, 2023, which created requirements for a referral to a specialist by a primary care or another specialist provider to comply with the required timeframe standards.

Why is this important?

Anthem is required by law to gather network appointment availability information from our providers to ensure members receive appointments within specific timeframes. We are regulated by the DMHC and CDI to monitor our provider network for prompt access to care and corrective action is taken if standards are not met or when providers refuse to participate in the survey. In certain circumstances, time-elapsed requirements may not be met, and Anthem recognizes these exceptions:

• Extending appointment wait time: The applicable waiting time for a particular appointment may be extended if the referring or treating licensed health care provider, or the health professional providing triage or screening services, as applicable, acting within the scope of his or her practice and consistent with professionally recognized standards of practice, 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. These services may be scheduled in advance consistent with professionally recognized standards of practice as determined by the treating licensed health care provider acting within the scope of his or her practice. 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 primary care appointment availability standard may be met if the PCP’s office provides advanced access. Advanced access means offering an appointment to a patient with a PCP (or nurse practitioner or physician’s assistant) within the same or next business day from the time an appointment is requested (or a later date if the patient prefers not to accept the appointment offered within the same or next business day). Note: This exception does not apply to commercial behavioral health.

24/7 NurseLine gives peace of mind

Anthem 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.

Help is a phone call away

For general questions or need 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 cannot obtain a timely referral to an appropriate provider or for more information about the regulations, visit the DMHC website at dmhc.ca.gov or call toll-free 888‑466‑2219 for help.

For patients with CDI-regulated health plans

If you or your patients cannot obtain a timely referral to an appropriate provider or for more information about the regulations, visit the CDI website at insurance.ca.gov or call toll-free 800‑927‑4357 for help.

Language assistance program

For members whose primary language is not English, Anthem offers free, language assistance services through interpreters and other written languages. If you or the member is interested in these services, please call the member services number listed on the member ID card for help (TTY/TDD: 711).

Questions

If you have questions about this communication, contact your assigned provider relationship management representative or visit anthem.com/ca/provider/contact-us for additional contact information.

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 difficulty and member abrasion. Achieving compliance is possible with your participation as our valued network provider.

We share a health vision with our care providers that means real change for consumers.