Timely Access Regulations and Language Assistance Program June 2024

2024 PAAS Surveys

Each year, Anthem, along with other health plans in California, conducts Provider Appointment Availability (PAAS) and After-Hours Surveys. These surveys are administered to specific randomly selected network providers. The PAAS Survey assists in evaluating whether members can obtain care provider appointments within time frames mandated by the Department of Managed Health Care (DMHC) and California Department of Insurance (CDI). The After-Hours Survey measures care provider compliance with the standards relating to the availability of emergency and after-hours service.

2024 surveys coming soon

Anthem contracts with a vendor to administer the surveys. Sutherland Healthcare Solutions will conduct the 2024 PAAS and After-Hours Surveys from July through December 31, 2024.

Understanding how to comply

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

• Compliant: Care provider offers an appointment within the required appointment time frames.
• Non-compliant: Care provider fails to offer an appointment within any of the required time frames or refuses to participate in the survey. Non-compliant care providers will receive a letter from Anthem requesting a Corrective Action Plan.
• Next available appointment date and time can be either in-person or by telehealth services.

Please take a moment to review and share with your staff the following access standards tables for medical and behavioral health professionals.

Access standards for medical professionals and ancillary care providers

Access standards for behavioral health and EAP care 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 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 care providers and 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.

As a reminder, in 2023, the DMHC expanded the list of physician and service type providers included in the PAAS. The table below identifies a current list of care providers included in the PAAS.

Keeping you informed

According to SB 221, effective January 1, 2023, a referral to a specialist by a primary care provider or another specialist should comply with the required time frame standards.

Why is this important?

Anthem is required by law to obtain appointment availability information from our network providers annually. We must ensure that our provider network can offer members an appointment within specific time frames. There are limits on how long members can wait to receive healthcare appointments and telephone advice.

The DMHC and CDI require that Anthem monitor its provider network and request a Corrective Action Plan if timely access to care standards are not met or if the provider refuses to participate in the survey.

Anthem recognizes 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 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 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 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 difficulties in obtaining a referral, members and providers can call the toll-free phone number on the back of the member ID card to speak with the Member Services team for Anthem. Representatives are available 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 care provider or for more information about the regulations, visit the DMHC website at 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 care provider or for more information about the regulations, visit the CDI website at 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 the Member Services number listed on the Anthem member ID card for help (TTY/TDD: 711).

Questions

If you have any questions about this communication, contact your assigned provider relationship account manager or visit anthem.com/ca/provider/contact-us to view additional contact information.

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!