Timely Access Regulations and Language Assistance program

Keeping you informed:

 

• The annual Provider Appointment Availability Surveys (PAAS) are currently in progress.  Review this information with your office staff so they are prepared and understand each provider’s responsibility to participate in the surveys.
• Each year, we communicate the Anthem Blue Cross (Anthem) Timely Access Regulations and Language Assistance Program to our commercial medical and behavioral health networks via an annual provider mailing. The 2022 mailing was completed in February.
• Effective July 1, 2022, Anthem implemented SB 221 — Timely Access Requirements for Non-Physician Mental Health/Substance Use Disorder Appointments.  For more details, review the Timely access regulations and language assistance program article in the March 2022 edition of Provider News.
• Effective January 1, 2023, SB 221 — A referral to a specialist by a primary care provider or another specialist shall be subject to the relevant time-elapsed standard.

 

Why is this important?

These are California state regulations.

 

Anthem is committed to keeping you, our network partners, updated on our activities related to our compliance with the Department of Managed Health Care (DMHC) and the California Department of Insurance (CDI) Timely Access to Non-Emergency Health Care Services Regulations (timely access regulations). 

 

To ensure compliance with these timely access regulations, three surveys are conducted annually. The surveys include, but are not limited to, the following:

• Provider Appointment Availability Survey
• Provider Satisfaction Survey
• Provider After-Hours Survey

 

Each year, we communicate Anthem’s Timely Access Regulations and Language Assistance Program to our commercial medical and behavioral health networks. The 2022 notice was mailed in February. This information also includes access to non-emergency healthcare services within prescribed timeframes (also referred to as the time elapsed standards or appointment wait times). We appreciate that in certain circumstances time-elapsed requirements may not be met. The timely access regulations have provided exceptions to the time-elapsed standards to address these situations:

• Extending appointment wait time: The applicable waiting time for a particular appointment may be extended if the referring or treating licensed healthcare provider, or the health professional providing triage or screening services, as applicable, acting within the scope of their 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 healthcare 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 primary care physician office provides advanced access. Advanced access means offering an appointment to a patient with a primary care physician (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 have access to our 24/7 NurseLine. A convenient way to ask questions or get advice from a registered nurse anytime. Locate the toll-free phone number on the back of the member ID card and the wait time is not to exceed 30 minutes.

 

Help is a phone call away

Members and providers have access to Anthem’s Member Services team for general questions or when having difficulty obtaining a referral to a provider. Call the toll-free phone number listed on the back of the member ID card for assistance. A representative may be reached within 10 minutes during normal business hours.

 

For patients (members) 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 California Department of Managed Health Care (DMHC) website at www.dmhc.ca.gov or call toll-free 888-466-2219 for assistance.

 

For patients (members) 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 Center for Diagnostic Imaging (CDI) website at www.insurance.ca.gov or call toll-free 800-927-4357 for assistance.

 

Language Assistance Program

For members whose primary language is not English, Anthem offers no-cost language assistance services through interpreters and other written languages. If you or the member is interested in these services, please call the Anthem Member Services number on the member’s ID card for help (TTY/TDD: 711).

 

We hope this clarifies Anthem’s expectations and your obligations regarding compliance with the timely access regulations. Our goal is to work with you to help successfully meet the expectations for the requirements with the least amount of difficulty and member abrasion. Anthem can only achieve this compliance with the help of our network providers — you! If you have any questions, visit the Contact Us page on our provider website. 

 

Take a moment to review and share the following appointment wait times with your staff the access standards tables for medical professionals and behavioral health that follow. The clock starts when the request for the appointment is made.

 

Access standards for medical professionals

Type of care	Maximum wait time after appointment request
Non-urgent appointments for PCP	10 business days
Urgent care (that does not require prior authorization)	48 hours
Non-urgent appointments with specialist physicians	15 business days
Urgent care (that requires prior authorization)	96 hours
Non-urgent appointment for ancillary services (for diagnosis or treatment of injury, illness, or other health condition)	15 business days
After-hours care	Available 24 hours per day, 7 days per week. Member to reach a recorded message or live voice response providing emergency instructions; and for non-emergent (urgent) matters, a mechanism to reach a health professional and information as to when to expect a call back.
Emergency care: Anthem expects every practitioner to instruct their after-hours answering service staff that if the caller is experiencing an emergency, the caller should be instructed to dial 911 or to go directly to the emergency room. Answering machine instructions must also direct the member to call 911 or go to the emergency room if the caller is experiencing an emergency.	Members are directed to dial 911 or go to the nearest emergency room.
Member Services by telephone:  Access to Member Services to obtain information about how to access clinical care and how to resolve problems. (This is a plan responsibility and not a physician responsibility. This also applies to our behavioral health members.)	Reach a live person within 10 minutes during normal business hours (Plan standard: 45 seconds; Call abandonment rate < 5%). The Member NurseLine is available 24/7 and the wait time is not to exceed 30 minutes.

Access standards for behavioral health and employee assistance program providers

Type of care	Maximum wait time after appointment request
Routine office visit/non-urgent appointment	10 business days (Psychiatrists)*   10 business days (Non-physician mental healthcare/substance use disorder provider)   10 business days from the prior appointment for those undergoing a course of treatment (Non-physician mental healthcare/substance use disorder)   5 business days (employee assistance plan [EAP])
Non-life-threatening emergency care	6 hours Members are directed to 911 or the nearest emergency room.
Urgent care (that does not require prior authorization)	48 hours
Urgent care (that requires prior authorization)	96 hours
After-hours care	Available 24 hours/7 days. Member to reach a recorded message or live voice response providing emergency care instructions, and for non-emergent (urgent) matters, a mechanism to reach a behavioral health/EAP provider and information as to when to expect a call back.
Emergency care:  Anthem expects every practitioner to instruct their after-hours answering service staff that if the caller is experiencing an emergency, the caller should be instructed to dial 911 or to go directly to the emergency room.  Answering machine instructions must also direct the member to call 911 or go to the emergency room if the caller is experiencing an emergency.	Members are directed to dial 911 or go to the nearest emergency room.

* 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.

Note:

 

• The next available appointment date and time can be either In-Person or by Telehealth services.
• Clinical advice may only be provided by appropriately qualified staff, a physician, physician assistant, nurse practitioner or registered nurse.

 

Questions

If you have any questions, contact your assigned Provider Experience associate, or visit the Contact Us page on our provider website. You can also email the Provider Experience team directly using the electronic form.

 

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