Access standards for PCP, specialists and behavioral health practitioners

As a participating provider, please be reminded of your contractual obligation to help ensure our members have prompt access to services. Please visit anthem.com to access our Provider Manual for our guidelines for access to care for primary care practitioners (PCPs), specialty care practitioners (SCPs) and behavioral health practitioners (BHPs).

 

We use the following methods to monitor adherence to these standards:

• Assessing the availability of services via phone calls by our staff or designated vendor to the provider’s office
• Analysis of member complaint data
• Analysis of member satisfaction

 

Providers are expected to make best efforts to meet these access standards for all members.

 

Here’s a quick reminder of our guidelines for PCPs:

• Preventive care – for members scheduling periodic routine exams (well care/preventive visits), appointments should be available within 45 calendar days of a member’s call. Care provided to prevent illness or injury; examples include, but are not limited to, routine physical examinations, immunizations, mammograms and pap smears.
• Urgent care services with acute symptoms – appointments should be available within 24 hours of the member’s call. Care provided for a non-emergent illness or injury with acute symptoms that require immediate care; examples include, but are not limited to, sprains, flu symptoms, minor cuts and wounds, sudden onset of stomach pain and severe, or non-resolving headache.   
• Routine check-up – members must have access to care within 10 business days of their call. Care provided for non-symptomatic visits for health check.
• After-hours access – members must have access to care 24 hours a day, 7 days a week, 365 days a year. PCPs must arrange after-hours care to provide 24-hour coverage for members by a network provider during non-business office hours. Members should have the ability to reach a recorded message or a live voice providing instructions on how to access care for emergencies and conditions requiring urgent attention.

 

Though it is important for members to have the continuity of receiving care from their PCPs, there are occasions when you may not be available at a time that meets their scheduling needs. As a reminder, we now contract with walk-in centers and urgent care facilities that are listed in our directory.

 

Here’s a quick reminder of our guidelines for SCP’s. At this time these guidelines apply to certain specialties but could expand to other specialties in the future. To view those current impacted specialties, please view the access standards on anthem.com.

• Urgent care services with acute symptoms – appointments should be available within 24 hours of the member’s call. Care provided for a non-emergent illness or injury with acute symptoms that require immediate care; examples include, but are not limited to, sprains, flu symptoms, minor cuts and wounds, sudden onset of stomach pain and severe, or non-resolving headache.  
• Routine check-up – members must have access to care within 30 calendar days of their call. Care provided for non-symptomatic visits for health check.

 

Here’s a quick reminder of our guidelines for BHPs:

• Non-life-threatening emergency services – must be seen, or have appropriate coverage directing the member, within six (6) hours. Emergent behavioral health care provided when a member is in crisis, experiencing acute distress and/or other symptoms and needs immediate attention; no risk of loss of life.
• Urgent services – must be seen, or have appropriate coverage directing the member, within 24 hours. Non-emergent behavioral health services that require immediate care; member is experiencing significant psychological distress with symptoms that impairs daily functioning; no risk of loss of life.  
• Initial routine services – must be seen within 10 business days. New patient non-urgent appointment scheduled after intake assessment or a direct referral from a treating practitioner.
• Follow-up routine services – must be seen within 30 calendar days. Non-urgent behavioral health care; member scheduled for a non-urgent consultation or requires services including, but not limited to, follow-up and existing medication management.
• BH follow-up appointment after discharge (inpatient psychiatric hospital release) – this standard is currently used for HEDIS® Members must be seen within 7 calendar days. Members can be seen in office by their practitioner or another practitioner in the practice within the same timeframe.
• After-hours access – members must have access to care 24 hours a day, 7 days a week, 365 days a year. Must have arrangement for after-hours care to provide 24-hour coverage for members by a network provider during non-business office hours. Members should have the ability to reach a recorded message or a live voice providing instructions on how to access care for emergencies and conditions requiring urgent attention.

 

After-hours urgent access coverage

After hours coverage, which is required by the Participating Provider Agreement, consists of an attendant or recording assisting the member in accessing urgent instructions outside of regular office hours. Note that telephone answering machines and voice mail are not acceptable means of providing urgent access for members if the answering machine or voice mail message only refers members to the emergency room or to call 911.

 

Compliance requires that a recording or live person directs callers to urgent care, 911, ER, or connects the call to the member’s doctor or the doctor on call. In addition to these measures, but not in place of them, the messaging can give callers the option of contacting their health care practitioner (via transfer, cell phone, pager, text, email, voicemail, etc.) or an opportunity to ask for a call back for urgent questions or instructions.

 

Timely access to physicians is a major priority of our members and employer groups. The requirements adopted reflect not only their expectations, but market norms. We will be assessing physicians against these requirements through our customer satisfaction surveys and provider surveys as well as follow-up on any members’ complaints received. However, we are sensitive to problems related to seasonal services, the varying nature of practice specialties, and the challenges faced by busy practices. If your office routinely fails to meet these access and after-hours standards, it is important that you document, and we understand, the reasons that the requirements are not met.

 

1327-1021-PN-NH