Access requirements for behavioral healthcare services

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 behavioral healthcare (BH). We will resume the survey in the second quarter of 2021, and expect that when members contact your office, you will be able to accommodate their urgent concerns after hours.

 

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 six 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 ME 48 hours CT and NH 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 ten business days .
  • 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 outcomes. It can be after the practitioners intake assessment or a direct referral from a treating 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 seven 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.

 

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.

 

Please note: It is imperative that your office updates any changes to your practice via the Provider Maintenance Form on anthem.com. Select Providers, your state, then under Provider Resources, select Provider Maintenance.

 

845-1220-PN-NE