AdministrativeCommercialDecember 1, 2020

Medical Access Standards

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 medical care. 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:

 

Medical Appointment Type

Compliance

Emergency Care

24/7 access

 

Immediate access at a facility, ER, 911 as appropriate

Urgent Care appointment

With acute symptoms

Within 24 hours

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

·         If appointment is unavailable, patient is directed to Urgent Care Center of ER, as appropriate.

 

Routine initial appointment with PCP

Routine non-urgent symptoms

Within 7 calendar days

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

 

After Hours access

Urgent instructions

24x7x365 phone access to PCP outside regular business hours

·         Live person connects caller to their Practitioner or on-call Practitioner.

·         Recording or live person directs patient to Urgent Care Center, 911 or ER

 

In addition to, but not in place if above criteria, caller is prompted to contact a live health care Practitioner (via transfer, cell phone page, etc.) or an opportunity to get a call back for urgent questions or instructions.

Specialty Urgent Care appointment

With acute symptoms

Within 24 hours

·         Patient can be seen in the office by their Specialist, another participating Practitioner in the practice or a covering Practitioner within the timeframe; or

·         If appointment is unavailable, patient is directed to Urgent Care Center of ER, as appropriate.

 

Specialty Routine / Check-up appointment

Without symptoms

Within 60 calendar days

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

 

 

 

861-1220-PN-CO

PUBLICATIONS: December 2020 Anthem Provider News and Important Updates -- Colorado