Appointment availability and after-hours access requirements

Category: Medicaid

 

To ensure members receive care in a timely manner, PCPs, primary care sites (PCS), specialty providers and behavioral health providers must maintain the following appointment availability and after‑hours access standards.

 

Appointment availability requirements

	PCPs:
	Appointment type	Appointment standard
	Medically necessary care	Same day
	Urgent care	Within two calendar days
	Routine care	Within two weeks
	After-hours access	Member must have access to communicate with provider after hours. See page two for specifics.
Specialists:
Appointment type	Appointment standard
Medically necessary care	Same day
Urgent care	Within three calendar days
Routine care	Within 30 days
Prenatal care, initial appointment	Initial prenatal care appointment will be provided for enrolled members who are pregnant as follows:
·         First trimester — within seven calendar days of the first request
·         Second trimester — within seven calendar days of the first request
·         Third trimester — within three calendar days of the first request
·         High risk — within three calendar days of the first request
Behavioral health providers:
Appointment type	Appointment standard
Care for nonlife-threatening emergency	Within six hours
Urgent care	Within 48 hours
Initial visit for routine appointment	Within 10 business days
Follow-up routine care	Within two weeks

 

After-hours access requirements

 

To ensure continuous 24-hour coverage, PCPs/PCS must maintain one of the following arrangements for members to contact them after normal business hours:

 

• Have the office telephone answered after hours by an answering service that can contact the PCP/PCS or another designated network medical practitioner. All calls answered by an answering service must be returned within 30 minutes.
• Have the office telephone answered after normal business hours by a recording in the language of each of the major population groups served by the PCP/PCS to direct the member to call another number to reach the PCP/PCS or another provider designated by the PCP/PCS. Someone must be available to answer the designated provider’s telephone. Another recording is not acceptable.
• Have the office telephone transferred after office hours to another location where someone will answer the telephone and be able to contact the PCP/PCS or a designated

Anthem Blue Cross and Blue Shield Healthcare Solutions network medical practitioner who can return the call within 30 minutes.

 

The following telephone answering procedures are not acceptable:

 

• The office telephone is only answered during office hours.
• The office telephone is answered after hours by a recording that tells members to leave a message.
• The office telephone is answered after hours by a recording that directs members to go to an emergency room for any services needed.
• After-hours calls are returned outside of 30 minutes.

 

What if I need assistance?

 

If you have questions, contact your local Provider Relations representative or call Provider Services at 1-844-396-2330.

 

ANV-NU-0049-19 April 2019