Appointment availability and after-hours access requirements

To ensure members receive care in a timely manner, primary care providers (PCP), specialists, and behavioral health (BH) providers must maintain the following appointment availability and after-hours access standards as required by the Department for Medicaid Services and Anthem Blue Cross and Blue Shield Medicaid.

 

General appointment scheduling (PCPs and all specialists, including vision, lab and radiology)
Emergency examination	Immediate access 24/7
Urgent examination	Within 48 hours of request
Routine examination	Within 30 calendar days of request
Voluntary family planning Members under 18 years of age	Within 30 calendar days of request If complete medical services cannot be provided on short notice, counseling and a medical appointment shall be provided right away, if possible, or within 10 calendar days of request.
Prenatal	Within 14 calendar days of request
Third trimester	Within five calendar days of request
High risk pregnancy	Within 14 calendar days of request
Postpartum exam	Four to eight weeks after delivery
Behavioral health appointment standards
Life-threatening emergency	Immediately
Crisis stabilization	Within 24 hours of request
Urgent behavioral health services	Within 48 hours of request
Outpatient treatment post-psychiatric inpatient care	Within seven calendar days from the date of discharge
Routine behavioral health visits, including the initial visit and follow-up visits	Within 10 calendar days of request
General and pediatric dental care appointment standards
Urgent examination	Within 48 hours of request
New patient exam (dental)	Within 30 calendar days of request
Routine exam after initial diagnosis (dental)	Within 30 calendar days of request

 

After-hours access requirements

 

PCPs are required to abide by a set of standards to ensure access to care for Anthem Blue Cross and Blue Shield Medicaid members. PCPs must:

• Offer members access to quality, comprehensive healthcare services 24/7.
• Have either a recording or an answering service for members during after-hours for assistance that follow the acceptable after-hours arrangements:
  • Office phone is answered after hours by an answering service that can contact the PCP or another designated medical practitioner and the PCP or designee is available to return the call within a maximum of 30 minutes;
  • Office phone is answered after hours by a recording directing the enrollee to call another number to reach the PCP or another medical practitioner whom the provider has designated to return the call within a maximum of 30 minutes; and
  • Office phone is transferred, after office hours to another location where someone shall answer the phone and be able to contact the PCP or another designated medical practitioner within a maximum of 30 minutes
• Be available to provide medically necessary services or from another
• Follow the referral/precertification guidelines. This is a requirement for covering
• For emergent issues, both the answering service and answering machine will direct the member to call 911 or go to the nearest emergency

 

Additionally, we strongly encourage offering after-hours appointments in the evenings and on Saturdays. For additional information regarding access and availability, please reference the provider manual on the provider page at https://providers.anthem.com/kentucky-provider/home.

 

What if I need assistance?

If you have questions, contact your local Provider Experience consultant or call Provider Services at 855-661-2028.

 

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