Physician Access/Appointment Availability Standards

General Availability Standards

Members must be able to access their PCP 24 hours a day, 7 days a week. As the Member’s healthcare manager, the PCP is responsible for providing or arranging healthcare services on a 24/7 basis. (An answering machine does not suffice as access to the Provider.) The PCP must also have a method to inform his or her Anthem Members about regular office hours and how to obtain care after office hours.

When off-duty or otherwise unavailable, the PCP must arrange for back-up coverage by a network physician so that appropriate medical care is available to Members at all times. The PCP must have available the name, telephone number and address of the physician(s) responsible for providing back-up services to patients. The PCP should contact Anthem Physician Services at 800-552-6630, 8:30 a.m. to 5:00 p.m. ET, Monday to Friday or Provider Data Management via fax at 518-367-3103 if the designated back-up changes.

The designated back-up physician(s) must participate in the same network and be a comparably trained practitioner as noted below:

• Family Practice – can be backed up by a Provider with the following specialties:
  Family Practice; General Practice and/or a combination consisting of Internal Medicine – for adults and Pediatrics for Children.
• General Practice – can be backed up by a Provider with the following specialties:
  Family Practice; General Practice and/or a combination consisting of Internal Medicine –for adults and Pediatrics for Children.
• Internal Medicine – can be backed up by a Provider with the following specialties:
  Internal Medicine or Family Practice.
  Pediatrics – can be backed up by a Provider with the following specialties:
  Family Practice or Pediatrics

The back-up physician is responsible for communicating with the PCP about patient care he or she rendered. Documentation of all healthcare services provided by the back-up physician must be summarized in the patient’s medical record including all pertinent Facility services.

If a Member is out of the area and contacts Anthem with an urgent or emergent situation, the patient will be informed to call his or her PCP directly. If this is not possible, the patient will be told to contact the PCP’s back-up physician.

Annually, Anthem will conduct an audit of the after hour availability coverage for PCP network participation to ensure compliance.

Compliance will be met if:

• A live person is reached within two (2) phone calls.
• If an answering service is reached; compliance will be met if the service is cooperative in confirming their association with the physician and identifies how the physician can be reached (ex. pager; calls patched to physician)

In no event shall the messages refer the Member to the ER unless it is a true emergency or advise to call back during normal business hours.

Appointment Availability Standards

The following are considered minimums for patient accessibility. Obviously, excellent care and service will often require significantly better performance.

For HMO and POS Members, the PCPs must be in the office treating patients a minimum of 16 hours a week per office location.

Patients should not wait for more than 15 minutes past their appointment time without an explanation about the delay and if necessary, provided with an opportunity to reschedule the appointment.

• The physician must be able to schedule appointments within the following time frames:
• Type of Appointment Time Frame
• Routine baseline physical exam Within 4 weeks
• Routine follow-up care Within 2 weeks
• Urgent Care Within 24 hours
• Non-Urgent Care Within 5 days
• Emergency Care Within 2 hours or triage to emergency room
• Initial prenatal exam Within 3 weeks
• Initial newborn exam Within 2 weeks
• Availability standards will be monitored through:
  • On-site visits by Network Management Consultant,
  • Review of appointment books,
  • Member satisfaction surveys, and
  • Member complaints

PHYSICIAN RESPONSIBILITIES

All participating Providers are expected to comply with certain standards regardless of the networks in which they participate. These include:

• Following Anthem’s access/appointment availability standards
• Following Anthem’s managed care requirements (if applicable to the Member’s benefit plan). Adhering to Anthem’s standard practice guidelines
• Submitting Claims for Members, accepting program/network fee schedule and not balance billing Members for covered services
• Not prohibiting Members from completing Anthem surveys and/or otherwise expressing their opinion regarding services received from physicians or Providers
• Will not differentiate or discriminate against any Member as a result of his/her enrollment in a Plan, or because of race, color, creed, national origin, ancestry, religion, sex, marital status, age, disability, payment source, state of health, need for health services, status as a litigant, status as a Medicare or Medicaid beneficiary, sexual orientation, or any other basis prohibited by law. Provider shall not be required to provide any type, or kind of Health Service to Covered Members that it does not customarily provide to others.

HMO Physicians

Physicians participating in the HMO-based networks have certain additional responsibilities, based upon their roles as primary care physicians and/or referral specialists.

Primary Care Physicians

A Primary Care Physician (PCP) is a family physician/family practitioner, general practitioner, internist or pediatrician who is responsible for delivering and/or coordinating care. PCPs must:

• Be accessible 24 hours a day, 7 days a week, and provide back-up coverage
• Provide or arrange for all care delivered to HMO Members
• Provide written referrals to referral specialists, to the extent required by the Member’s benefit plan