Timely Access Regulations and Language Assistance Program

Keeping you informed:

• 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 2023 mailing was completed in January.
• Effective July 1, 2022, Anthem implemented SB 221 – Timely Access Requirements for Non-Physician Mental Health/Substance Use Disorder Appointments. See the access standards charts on the pages that follow for more information.
• 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.
Blue Cross of California dba Anthem Blue Cross and Anthem Blue Cross Life & Health Insurance Company (collectively, 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 (the Timely Access Regulations), respectively.

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 

In 2023, the annual surveys will begin in July or August and will continue through December 31.

Beginning with the 2023 Provider Appointment Availability Survey (PAAS), the DMHC expanded the types of specialist physicians who are included in the PAAS. Below is a complete list of provider types and specialties who will be included in the PAAS.

Each year, we communicate Anthem’s Timely Access Regulations and Language Assistance Program to our commercial medical and behavioral health networks. The 2023 notice was mailed in January. 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 their 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 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 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, at no cost, language assistance services through interpreters and other written languages. If you or the member is interested in these services, please call Anthem’s 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 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!

Take a moment to review and share the following appointment wait times with your staff and 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

Access Standards for Behavioral Health and Employee Assistance Program (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

• Note: The next available appointment date and time can be either in person or by telehealth services.
• Only appropriately qualified staff, a physician, physician assistant, nurse practitioner, or registered nurse are allowed to 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 delay on the scheduling of 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 specialists: A referral to a specialist by a primary care provider or another specialist shall be subject to the relevant time access standards.

Questions
If you have any questions about this communication, contact your assigned Provider Relationship Management representative or visit anthem.com/ca/provider/contact-us to view additional contact information.