Your contract with Anthem requires that your practice provide timely access to care for our members. Listed below are the Appointment Access standards for both Medical and Behavioral health Providers.

 

Medical Access Standards


Medical Appointment Type

Compliance

Emergency Care

24/7 access

 

Immediate access at a facility, ER, 911, as appropriate.

Urgent Care appointment

 

Non-emergent care with significant. Calls are urgent when the severity or nature of presenting symptoms is intolerable, but not life threatening to the member.

Within 24 hours

 

  • Patient can be seen in the office by their PCP or another participating provider in the practice or a covering provider; and
  • If appointment is unavailable, patient is directed to Urgent Care Center, 911 or ER, as appropriate.

Routine initial appointment with PCP

 

New patient non-urgent appointment.

Within 7 calendar days

 

New patient can be seen in the office by or provider within the timeframe.

Preventive visit/well visits

 

Patients can get an appointment for preventive visit or well visits.

Within 30 calendar days

 

Patient can be seen in the office by their PCP or another participating provider in the practice within the timeframe.

Prenatal Care - initial visit

 

PCPs that handle prenatal care and OB/Gyns

 

Patients can get an appointment with their PCP or OB/Gyn for initial prenatal care.

Within 7 calendar days

 

Patient can be seen in the office by their PCP or OB/Gyn within the timeframe.

Specialty urgent care

 

Contacting a specialist for  urgent care

Within 24 hours

 

Patient can be seen in the office by their specialty provider in the practice within the timeframe.

Specialty Routine Care

 

Contacting a specialist for non-urgent care

Within 60 calendar days

 

Patient can be seen in the office by their Specialist within the timeframe.

After Hours Urgent Access

 

Contacting Primary Care Provider for emergency and urgent instructions.

24X7 phone access

 

  • Live person connects caller to their Practitioner or on-call Practitioner.
  • Recording or live person; instructs the caller to hang up and go to ER or call 911 for emergencies  or Urgent Care Center, 911 or ER, for urgent, as appropriate.  

 

In addition to, but not in place if above criteria, caller is offered to contact their PCP or on-call provider (via cell, pager, beeper, transfer system) or get a call back for urgent questions or instructions.


Behavioral Health Access Standards

                                                  

Behavioral Health: Note that Anthem may use prescribing nurse practitioners for availability, if they are in the scope of credentialing, as licensed independent practitioners. These same professionals will be included in the access assessment.


Behavioral Health Appointment Type

Compliance

Emergency Care

24x7 phone access to BH practitioner

 

Recording or live person instructs the caller to hang up and call 911, go to ER or Crisis Center for emergencies

Non-life threatening Emergent appointment

 

Members under acute distress, whose ability to conduct themselves for their own safety, or the safety of others, may be time-limited, or in response to a catastrophic life event or indications of active substance use or threat of relapse. Situation has the potential to escalate into an emergency without clinical intervention.

Within 6 hours

 

  • Patient can be seen in the office by their BH Practitioner, another participating Practitioner in the practice or a covering Practitioner; or
  • If appointment is unavailable, patient directed to 911, ER or 24 hour crisis services, as appropriate.

Urgent Care appointment

Non-emergent care with significant psychology distress and symptoms. Calls are urgent when the severity or nature of presenting symptoms is intolerable, but not life threatening to the member.

Within 24 hours

 

  • Patient can be seen in the office by their BH Practitioner, another participating Practitioner in the practice or a covering Practitioner; or
  • If appointment is unavailable, patient directed to 911, ER or 24 hour crisis services, as appropriate.

Routine initial appointment

 

New patient non-urgent appointment.

Within 7 calendar days

 

New patient can be seen in the office by a designated BH Practitioner or another appropriate participating Practitioner in the practice.

 

(After the intake assessment or a direct referral from a treating Practitioner.)

Routine follow-up appointment

 

New or existing patient

 

Evaluation of progress or members who present

no immediate distress and can wait to schedule an appointment without any adverse outcomes.

Within 30 calendar days

 

Patient can be seen in the office by their BH Practitioner, another participating Practitioner in the practice or a covering Practitioner within the timeframe.

After Hours Urgent Access

 

Contacting BH Practitioners for emergency and urgent instructions.

24X7 phone access

 

  • Live person connects caller to their Practitioner or on-call Practitioner
  • Recording or live person refers patient to ER / 911 / 24- hour crisis services;

 

In addition to, but not in place if above criteria, caller is offered to contact a BH professional (via cell, pager, beeper, transfer system) or get a call back for urgent instructions or consultation.


Anthem uses several methods to monitor adherence to these standards, including:

  1. assessing the availability of appointments via phone calls and surveys by our designated vendor to the provider’s office;
  2. analysis of member complaint data; and
  3. analysis of member satisfaction.

 

Providers are expected to make best efforts to meet these access standards for all members.

 

Is your practice compliant?






Featured In:
January 2019 Anthem Provider Newsletter - CO