Access requirements for behavioral healthcare services

Note to staff: It is imperative that your office updates any changes to your practice via the Provider Maintenance Form (PMF).  Access the PFM online at anthem.com.  Select Providers, and your state.  Under the Provider Resources heading, select Provider Maintenance Form.

 

The impact of COVID-19 in 2020 prohibited Anthem from conducting the annual appointment access studies to assess how well practices meet appointment access requirements for our members for behavioral healthcare (BH). We will resume the survey in second quarter 2021 and expect when your office is contacted, you will be able to accommodate a member’s needs in a timely manner.

 

To be compliant, per the Provider Manual, providers should meet the following access standards:

 

• Non-life-threatening emergency – The patient must be seen in the office by their BH Practitioner, another Practitioner in the practice or a covering Practitioner within 6 hours. If unable, the patient will be referred to 911, ER or 24-hour crisis services, as appropriate.
  • Explanation - These calls concern members in 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. The situation has the potential to escalate into an emergency without clinical intervention.

• Urgent – The patient must be seen in the office by their BH Practitioner, another Practitioner in the practice or by a covering Practitioner within 24 hours.   
• Explanation - These calls are non-emergent with significant psychological distress, when the severity or nature of presenting symptoms is intolerable but not life threatening to the member.
• Initial Routine office visit – A new patient must be seen in the office by a designated BH Practitioner or another equivalent Practitioner in the practice within 7 calendar day.  It can be after the Practitioner intake assessment or a direct referral from a treating Practitioner. 
• Explanation – This is a routine call for a new patient defined as a patient with non-urgent symptoms, which present no immediate distress and can wait to schedule an appointment without any adverse outcomes.
• Routine office visit – The patient must be seen in the office by their BH Practitioner, another Practitioner in the practice or by a covering Practitioner within 30 calendar days.
• Explanation - These calls concern existing members, to evaluate what has taken place since a previous visit, including med management. They present no immediate distress and can wait to schedule an appointment without any adverse outcomes.

• BH follow-up appointment after discharge – The patient must be seen in the office by their Practitioner or another Practitioner in the practice within 7 calendar days.
  • Explanation – These calls concern members being released from inpatient psychiatric hospital care, requesting a follow-up appointment to evaluate what has taken place since release, including med management.
• After Hours Urgent access – 24x7x365 phone access outside regular business hours
  • Explanation – A member can reach a live person, which connects caller to their BH Practitioner or on-call Practitioner or a recording or live person directs patient to Urgent Care Center, 911, ER, or Crisis Center
    • Addition to, but not in place if above criteria, caller is prompted to contact a live health care BH Practitioner (via transfer, cell phone page, etc.) or an opportunity to get a call back for urgent questions or instructions.

 

Methods used to monitor adherence to these standards consist of assessing the accessibility of appointments via phone calls from North American Testing Organization, a vendor working on Anthem’s behalf, and analysis of member complaint and member experience data.

 

 

845-1220-PN-CONV