Behavioral healthcare appointment access requirements
The annual behavioral health access studies performed by our vendor, North American Testing Organization based in California, were resumed and fielded during the first through third quarters of 2021. The purpose is to assess adequate appointment timeframes for our members with an urgent condition or for routine follow-ups.
The main challenges the vendor encounters while attempting to collect this required, essential data are related to inaccurate provider information in Anthem’s demographic database, i.e. incorrect or non-working phone numbers; practitioner moved, retired, or deceased; the practice has resigned their Anthem contract, accepts private pay only, or is no longer in practice; as well as, staff refusing to participate in the survey. We ask that you update office information using the online Provider Maintenance Form and that you participate in quality programs such as this critical survey as a condition of Anthem’s contract.
The primary appointment type not meeting compliance is consistently obtaining the initial routine appointment. This is the initial conversation with a professional after the intake assessment for a new patient for a non-urgent condition. Please refer to compliant timeframe and explanation below.
To be compliant, per the Provider Manual, participating providers agree to meet the following access standards, whether in person or a telehealth visit:
- Non-life-threatening emergency – The patient must meet with their BH practitioner, another practitioner in the practice or a covering practitioner within 6 hours. If unable, the patient will be referred to 911, ER or 24-hour crisis services, as appropriate.
- Explanation - These calls concern members in acute distress whose ability to conduct themselves for their own safety, or the safety of others, may be time-limited, or in response to a catastrophic life event or indications of active substance use or threat of relapse. The situation has the potential to escalate into an emergency without clinical intervention.
- Urgent – The patient must meet with their BH practitioner, another practitioner in the practice or by a covering practitioner within 48 hours.
- Explanation - These calls are non-emergent with significant psychological distress when the severity or nature of presenting symptoms is intolerable but not life threatening to the member.
- Initial routine office visit – A new patient must meet with a designated BH practitioner or another equivalent practitioner in the practice within 10 business days. It can be after the intake assessment or a direct referral from a treating practitioner.
- Explanation – This is a routine call for a new patient defined as a patient with non-urgent symptoms which presents no immediate distress, and can wait to schedule an appointment without any adverse outcomes.
- Routine office visit – The patient must meet with their BH practitioner, another practitioner in the practice or by a covering practitioner within 30 calendar days.
- Explanation - These calls concern existing members to evaluate what has taken place since a previous visit, including med management. They present no immediate distress and can wait to schedule an appointment without any adverse outcomes.
- BH follow-up appointment after discharge – The patient must meet with their practitioner or another practitioner in the practice within 7 calendar days.
- Explanation – These calls concern members being released from inpatient psychiatric hospital care requesting a follow-up appointment to evaluate what has taken place since release, including med management.
December 2021 Anthem Provider News - Wisconsin