Access surveys for PCPs, specialists and behavioral health practitioners to be conducted

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 several methods to monitor adherence to these standards. Monitoring is accomplished by:

 

• 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, 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 our 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 which 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 will expand to other specialties in the near 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, 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 requires 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 has been 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 ® measures. 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 our 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.