Access standards for PCPs, specialists and behavioral health practitioners in 2018

Anthem Blue Cross and Blue Shield and our 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, and those methods include:

a.  Assessing the availability of appointments via phone calls by our staff or designated vendor to providers’ offices.

b.  Analysis of members’ complaint data.

c.  Analysis of members’ 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 – 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.

 

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 – Members must have access to care within 30 calendar days of their call. Care provided for non-symptomatic visits for health check.

 

Guidelines for behavioral health practitioners (BHPs):

 

• Non-life threatening emergency needs – Members 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 needs – Members 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 – Members 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 – Members 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. 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.

 

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