Timely access to care course and standards

Care providers now have access to the Timely Access Training Course. This required training can be found at https://tinyurl.com/TimelyAccessTrainingCourse.

To ensure comprehensive care, care providers must maintain accessibility standards for covered services across various times and settings. Access to covered services must be available during weekday office hours, and a provider or designated agent must be available by phone after hours, on weekends, and on holidays. Care providers must arrange on‑call coverage when unavailable with another participating care provider. If access standards are not met, care providers could be subject to contractual sanctions for breach of contract.

After‑hours calls:

• After‑hours answering services must respond to the After‑Hours Survey questions.
• Answering services or after‑hours staff must ask if the call is an emergency and direct members to call 911 or visit the nearest emergency room (ER) if needed.
• If staff or the service is unavailable, an answering machine must instruct on emergencies and provide alternative contact details for the primary care physician (PCP) or on‑call care provider.
• For emergencies, non‑English speakers should receive messages in their language that direct them to call 911 or go to an ER.
• In non‑emergencies, members should get instructions to contact the on‑call provider. Answering services must know how to reach a telephone interpreter and ensure all calls are returned.

Appointment access

Note: The next available appointment date and time can be in‑person or via telehealth services.

Healthcare providers must make appointments for members from the time of request as follows:
SB221 — Effective July 1, 2022, non‑physician mental health/SUD appointments are subject to the timely access standards outlined in the chart above. This bill also requires that all health plans ensure that enrollees undergoing a course of treatment for an ongoing mental health or SUD condition can schedule a follow‑up appointment with their non‑physician mental health services or SUD provider within 10 business days of the prior appointment.

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 results of the visit should be sent to the PCP’s office to allow continuity of care.

Wait times:

• When a member calls a provider’s office during regular business hours or after‑hours for assistance and possible triage, the provider or staff member must take the call or call the member back within 30 minutes of the initial call.
• When a member arrives on time to an appointment, the member should be seen within 15 minutes of the scheduled appointment.
• When members or prospective members call a physician’s office, they should not be placed on hold for longer than 10 minutes.

Interpretation services

The provider’s office should know how to contact a telephone interpreter to communicate with the member in the member’s preferred language.

Noncompliance

Compliance with these standards is a contractual requirement. We monitor compliance through a number of mechanisms, including annual phone surveys, to determine if participating provider offices meet the above standards.

For additional details, review the provider manual.

Since 2023, network providers are measured based on a compliance threshold of 70% for urgent and non‑urgent appointments, and 80% compliance for a non‑physician mental health follow‑up appointment 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.

Rescheduling missed appointments — Los Angeles County providers only

Los Angeles County providers are required to call to reschedule within 48 hours after a missed appointment. Providers may be surveyed on a random sample to ensure compliance, so update your office’s policies and procedures and training to include this requirement.

Schedule of timely access surveys

DHCS administers the surveys, and the surveys are provided to Anthem after each quarter.

• Provider Appointment Availability Survey (PAAS):
• Survey subject(s): Appointment Availability
• Contractor conducting survey: Sutherland
• Regulatory agency: Department of Managed Health Care (DMHC)
• Schedule: July through November 2024
• After Hours and Appointment Availability Survey:
• Survey subject(s): Emergency and urgent after‑hours calls
• Contractor conducting survey: TBD
• Regulatory agency: National Committee for Quality Assurance (NCQA); DMHC
• Schedule: October through November 2024
• Primary Care and Specialty Care Appointment Availability Survey:
• Survey subject(s): Appointment availability, interpretation services
• Conducting/regulatory agency: Department of Health Care Services (DHCS)
• Schedule:
• Q1: January through March
• Q2: April through June
• Q3: July through September
• Q4: October through December

Top reasons for noncompliance with the Provider Appointment Availability Survey:

• Appointment not available within DMHC standards
• No provider/ facility by this name
• Provider left group
• Number not in service
• Hospitalist/ No Appointments at this location
• Fax tone – Incorrect phone number
• Provider listed under incorrect specialty
• Provider (or group) not in plan network
• No longer at location
• Provider ceasing to practice
• Provider deceased

Top reasons for noncompliance with the Provider After‑Hours Survey:

• Patient with an emergency situation was not told to call 911 or to proceed to ER
• Did not receive a callback within 30 minutes
• Recording does not include emergency instructions
• No answer
• Recorded message that does not provide a way to reach a live party
• Patient is unable to speak to a provider within 30 minutes
• No answer after following message prompts to reach a live party
• Refused to complete survey

Remediation suggestions:

• Have schedulers take the Timely Access Training Course.
• Make sure schedulers are aware of timely access standards.
• Have schedulers hang up Timely Access Flier in their front office.
• Have schedulers leave some appointments open each day for urgent appointments
• Utilize telehealth for timely access.
• Make sure Anthem has the correct provider demographic information.
• Update Anthem immediately with any provider demographic changes.
• Providers confirm recorded message/answering services instruct members to call 911 or go to the nearest ER in case of emergency.
• Providers confirm that patients can have a provider call them back within 30 minutes if they call in with an urgent condition.

Quarterly notes

The California Department of Health Care Services (DHCS) conducts its own independent quarterly timely access surveys. Provider offices must comply with these survey requests.