AdministrativeDentalOctober 1, 2024

Timely Access Regulation and Language Assistance program

We are committed to keeping you, our network partners, updated on our activities related to our compliance with the Department of Managed Health Care (DMHC) and the California Department of Insurance (CDI) Timely Access to Non-Emergency Health Care Services Regulations (the Timely Access Regulations).

We maintain policies, procedures, and systems necessary to ensure compliance with the Timely Access Regulations, including access to non-emergency healthcare services within prescribed timeframes (also referred to as the time elapsed standards or appointment wait times). We can only achieve this compliance with the help of you, our provider network partners.

The following chart includes the access standards that providers are required to meet.

Access standards for dental professionals

Access to

Standard

Non-urgent appointments for primary dental care (PCP)

Must offer the appointment within 36 business days of the request

Urgent care appointments (defined as severe pain, loss of life, limb, or major bodily function)

Must offer the appointment within 72 hours of request

Initial visits of dental examinations and X-rays for primary dental care (PCP)

Must offer the appointment within 36 business days of the request

Hygiene visits for primary dental care (PCP)

Must offer the appointment within 40 business days of the request

In-office waiting room time

Usually, members do not wait longer than 45 minutes to see a dentist or their designee.

After-hours care (when dental office is closed)

Member to reach a recorded answering machine message or live answering service voice response providing instructions on how to obtain urgent or emergency care including, when applicable, how to contact another dentist who has agreed to be on call to triage or screen by phone, or if needed, deliver urgent or emergency care

Emergency appointments (defined as a dental condition that exhibits unresolved pain, excessive bleeding, or swelling below the jaw)

Emergency appointments need to be available as necessitated by the patient’s condition, requiring the dentist to be on call to assess the patient’s needs and determine appropriate appointment scheduling. By contract, participating providers are required to be available 24 hours a day, seven days a week for emergencies and are required to provide an after-hours answering system, which could consist of an answering service, a recording device, a pager system and to return of a call to the member within two hours to assess the nature of the emergency. Must offer the appointment within 24 hours of request

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 their 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.

The following chart includes the access standards we are required to meet.

Access to

Standard

Contacting Member Services by telephone to obtain information about how to access clinical care and how to address and/or resolve problems (this is a plan responsibility and not a provider network partner responsibility)

Within 10 minutes to reach a live person by phone during normal business hours

If you have further questions, please contact us at 866-947-9398.

For patients with Department of Managed Health Care regulated health plans:
If you or your patients are unable to obtain a timely referral to an appropriate provider or for additional information about the regulations, visit the Department of Managed Health Care’s website or call 888-466-2219 for assistance.

For patients with California Department of Insurance regulated health plans:
If you or your patients are unable to obtain a timely referral to an appropriate provider or for additional information about the regulations, visit the Department of Insurance’s website at insurance.ca.gov or call 800-927-4357 for assistance.

Language Assistance program

We offer members free language assistance services using interpreters for both verbal and written communications. If you or the member are interested in these services, please call the Member Services number on the member’s ID card for help (TTY/TDD: 711). For more information, refer to Anthem’s Dental Language Assistance Program for your office article in this newsletter.

We hope this clarifies our expectations and your obligations regarding compliance with the Timely Access Regulations. Our goal is to work with our providers to successfully meet the expectations for the requirements with the least amount of difficulty and member abrasion.

Anthem Blue Cross is the trade name of: In California: Blue Cross of California and Blue Cross of California Partnership Plan, Inc. Anthem BC Health Insurance Company is the trade name of Anthem Insurance Companies, Inc. Blue Cross of California, Blue Cross of California Partnership Plan, Inc., Anthem Blue Cross Life and Health Insurance Company, and Anthem BC Health Insurance Company are independent licensees of the Blue Cross Association. In 11 northeastern counties of New York: Anthem HealthChoice Assurance, Inc. and Anthem HealthChoice HMO, Inc. In these same counties, Anthem Blue Cross Retiree Solutions is the trade name of Anthem Insurance Companies, Inc. Independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

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PUBLICATIONS: October 2024 Dental Provider Newsletter