Policy Updates Medical Policy & Clinical GuidelinesMedicaidSeptember 14, 2023

Required timely access training

Anthem Blue Cross (Anthem) encourages participating providers and their front office staff to now take the Supporting Our Members learning module, under the Getting Started Pathway by October 30, 2023. Supporting Our Members - Timely Access Training.

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.

Appointment access

Note: The next available appointment date and time can be either In-Person or by telehealth services. Healthcare providers must make appointments for members from the time of request as follows:

General appointment scheduling

Emergency examination

Immediate access, 24/7

Urgent (sick) examination

Within 48 hours of request, excluding holidays and weekends, if authorization is not required OR within 96 hours of request, excluding holidays and weekends, if authorization is required, or as clinically indicated

Routine primary care examination (nonurgent)

Within 10 business days of request

Nonurgent consults/specialty referrals

Within 15 business days of request

Nonurgent care with nonphysician mental health provider or substance use disorder provider (where applicable)

Within 10 business days of request

Nonurgent follow-up care with non-physician mental health provider or substance use disorder provider

Within 10 business days of request

Nonurgent ancillary

Within 15 business days of request

Mental health appointment, nonphysician

Within 10 business days of request

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 healthcare 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.

SB221

Effective since July 1, 2022, non-physician mental health/substance use disorder appointments are subject to the timely access standards outlined in the chart above. This bill also requires that all health plans ensure that enrollees who are undergoing a course of treatment for an ongoing mental health or substance use disorder condition can schedule a follow up appointment with their non-physician mental healthcare or substance use disorder provider within 10 business days of the prior appointment.

Services for members under the age of 21 years

Initial health assessments:

Children from birth to 20 years of age

Within 120 days of enrollment

Preventive care visits

Within 14 days of request

Services for members 21 years of age and older

Initial health assessments

Within 120 days of enrollment

Preventive care visits

Within 14 days of request

Routine physicals

Within 30 days of request

Prenatal and postpartum visits

1st and 2nd trimester

Within 7 days of request

3rd trimester

Within 3 days of request

High-risk pregnancy

Within 3 days of identification

Postpartum

Between 21 and 56 days after delivery

Long-term services and supports

Skilled nursing facility

  • Rural and small counties — within 14 business days of request
  • Medium counties — within seven business days of request
  • Dense counties — within five business days of request

Intermediate care facility/developmentally disabled (ICF-DD)

  • Rural and small counties — within 14 business days of request
  • Medium counties — within seven business days of request
  • Dense counties — within five business days of request

Community-based adult services (CBAS)

Capacity cannot decrease in aggregate statewide below April 2012 level

Specialists

The following guidelines are in place for our specialists:

  • For urgent care, the specialist should see the member within 96 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 member during regular business hours as well as after hours for assistance and possible triage, the provider or another healthcare professional must either take the call or call the member back within 30 minutes of the initial call.
  • When an Anthem member arrives on time to an appointment, the member should be seen within 15 minutes of the scheduled appointment.
  • When Anthem members and/or prospective members call a physician’s office, they should not be placed on hold for longer than 10 minutes.

Interpretation services

When a provider’s office receives a call from an Anthem member, the provider’s office should know where to contact a telephone interpreter to communicate in the member’s preferred language.

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://tinyurl.com/bddw83wr. Beginning in 2023, delegated network providers will be measured based on a compliance threshold of 70% as outlined in CCR 1300.67.2.2. Delegates scoring below 70% compliance for non-urgent and urgent appointment availability will be subject to corrective action, up to and including termination of the contract.

CABC-CD-037365-23