Anthem Blue Cross and Blue Shield of Virginia and affiliate Healthkeepers, Inc. would like to remind all participating providers of their contractual obligation to ensure our members have prompt access to care and services. We use several methods to monitor adherence to these standards. Several of those methods include:

 

  • Assessing the availability of appointments via phone calls by our staff or designated vendor to the provider’s office

 

  • Analysis of member complaint data and

 

  • Analysis of member satisfaction

 

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

 

Guidelines for primary care physicians (PCPs):

 

Preventive care – members scheduling periodic routine exams (well care/preventive visits), appointments should be available within 60 calendar days of a member’s call. Care provided to prevent illness or injury.

 

Urgent care appointment 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.

 

Routine check-up – must have access to care within 10 business days of the member’s 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.

 

Compliance requires that a recording or live person directs callers to Urgent Care, 911, the ER, or connects the call to the caller’s physician or the physician 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 or voicemail) or an opportunity to ask for a call back for urgent questions or instructions.


Guidelines for specialists:

 

Urgent care appointment 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.

 

Routine check-up – must have access to care within 30 calendar days of the member’s call.  Care provided for non-symptomatic visits for health check.

 

Guidelines for behavioral health practitioners (BHPs):

 

Non-life threatening emergency needs – must be seen, or have appropriate coverage directing the member, within six (6) hours. Or, if appointment is unavailable, patient directed to 911, ER or 24-hour crisis services as appropriate.  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 needs – must be seen, or have appropriate coverage directing the member, within 24 hours. Non-emergent behavioral health illness that requires immediate care; member is experiencing significant psychological distress with symptoms that impairs daily functioning; no risk of loss of life.

 

Initial routine office visit – 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 visit – 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.

 

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. Compliance requires that a recording or live person directs callers to Urgent Care, 911, the ER, or connects the call to the caller’s physician or the physician 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 or voicemail) or an opportunity to ask for a call back for urgent questions or instructions.

 

These guidelines are also included in all participation agreements. To obtain a copy, providers should contact their Anthem provider network manager.



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December 2019 Anthem Provider News - Virginia