AdministrativeMedicaidDecember 1, 2023

Appointment availability and after-hours access requirements

To ensure members receive care in a timely manner, primary care providers (PCP), specialists, and behavioral health 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 (Anthem).

General appointment scheduling (PCPs and all specialists, including vision, laboratory, 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.

Pregnancy

Prenatal care

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 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.
    • 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 physician.
  • Follow the referral/precertification guidelines. This is a requirement for covering physicians.
  • Ensure that for emergent issues, both the answering service and answering machine direct the member to call 911 or go to the nearest emergency room.

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.

What if I need assistance?

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

Anthem Blue Cross and Blue Shield Medicaid is the trade name of Anthem Kentucky Managed Care Plan, Inc., independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

KYBCBS-CD-040747-23

PUBLICATIONS: December 2023 Provider Newsletter