Anthem Blue Cross and Blue Shield

Transcription

1 Anthem Blue Cross and Blue Shield Anthem webinar series Access to care standards Serving Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect

2 Operational responsibilities: Access to care Overview This webinar outlines Anthem s standards for timely and appropriate access to quality health care. Following guidelines set by the National Committee for Quality Assurance (NCQA), the American College of Obstetricians and Gynecologists (ACOG) and the Indiana Family and Social Services Administration (FSSA), these standards help ensure that medical appointments, emergency services and continuity of care for new and transferring members are provided fairly, reasonably and within specific time frames. We recognize that there can be cultural and linguistic barriers that affect our member s ability to understand or comply with certain instructions or procedures. In order to break through those barriers, we encourage providers to review Anthem s Caring for Diverse Populations toolkit which can be found at on the Provider Resources page under the Health Education heading. Anthem monitors provider compliance with access to care standards on a regular basis. Failure to comply may result in corrective action. For more information, please double click on the Access to Care PDF icon to open the document. 1

3 General appointment scheduling Emergency examinations: triaged and treated immediately on presentation at the PMP site Urgent examinations (members with persistent symptoms): treated no later than the end of the following work day after initial contact with the PMP site Non-urgent sick visits : within 72 hours Non-urgent routine examinations: within 21 days of request Wait in the waiting room: within 45 minutes If calling with immediate need: 30 minutes Initial Health Assessment: within 90 calendar days from the enrollment date Newborns: within 14 days of enrollment Children: within 60 days of enrollment Adults (18-21): within eight weeks of enrollment Source: Provider Operations Manual, chapter 15, pages

4 Prenatal and postpartum visits First trimester: within 14 calendar days of the request Second trimester: within seven calendar days of the request Third trimester: within three business days of the request (or immediately if an emergency exists) High-risk pregnancy: within three business days of the request (or immediately if an emergency exists) Postpartum exam: within three to eight weeks after delivery Source: Provider Operations Manual, chapter 15, page 177 3

5 Behavioral health visits Specialty care examinations: within three weeks of request Outpatient behavioral health examinations: within 14 days of request Routine behavioral health examinations: within 10 days of request Outpatient treatment: within seven days of discharge Post-psychiatric inpatient care: within seven days of discharge Source: Provider Operations Manual, chapter 15, page 176 4

6 After-hours services Answering service or after-hours personnel must: Forward member calls directly to the PMP or on-call provider, or instruct the member that the provider will contact the member within 30 minutes. Ask the member if the call is an emergency. In the event of an emergency, they must immediately instruct the member to dial 911 or proceed directly to the nearest hospital emergency room. Have the ability to contact a telephone interpreter for members with language barriers. Return all calls. Members can also call the 24-hour Nurse HelpLine to speak to a registered nurse. Nurses provide health information and options for accessing care, including emergency services, if appropriate. Source: Provider Operations Manual, chapter 15, page 178 5

7 After-hours services Answering machine messages: May be used in the event that staff or an answering service is not immediately available. Must instruct members with emergency health care needs to dial 911 or proceed directly to the nearest hospital emergency room. Must provide instructions on how to contact the PMP or on-call provider in a nonemergency situation. Must provide instructions in English, Spanish and any other language appropriate to the PMP practice. Please note: Anthem prefers that PMPs use an Anthem-contracted, in-network provider for on-call services. When that is not possible, the PMP must use his or her best efforts to help ensure that the on-call provider abides by the terms of the Anthem provider contract. Source: Provider Operations Manual, chapter 15, page 178 6

8 Thank you for serving our Anthem members! Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc., independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. AINPEC August