Appointment availability and access guidelines help ensure members have timely access to medical and behavioral health care services. Below are appointment access standards for providers participating in our commercial and Medicare Advantage plans. For a complete list of access and availability standards, refer to our provider manuals for commercial and Blue Cross Medicare Advantage (PPO)℠ plans, available on Availity® Essentials.
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Access to Care Standards
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Primary care access standards
Commercial primary careAppointment availability Emergency services Available and accessible at all times Urgent care appointments Immediately or refer to emergency room Appointments for non-urgent care with symptom Within seven business days Appointments for routine or preventive care Within 30 business days Scheduled follow-up outpatient visits Consistent with the clinical need
Participating providers are required to have 24-hour availability of emergency services and qualified on-call coverage available to our members.Emergency services means health care items and services furnished or required to evaluate and treat an emergency medical condition.
Emergency medical condition is a condition manifesting itself with symptoms of sufficient severity, including severe pain, in which the absence of immediate medical attention could reasonably be expected to result in any of the following:
- The covered person’s health would be in serious jeopardy
- The covered person’s bodily functions would be seriously impaired
- A body organ or part would be seriously damaged
Medicare Advantage primary careAppointment availability Urgent or emergency care Immediately or refer to emergency room Symptomatic non-urgent care Within seven business days Routine and preventive care Within 30 business days
Emergency medical condition is a condition of a recent onset and severity, including but not limited to severe pain, that would lead a prudent layperson possessing an average knowledge of medicine and health to believe that his or her condition, sickness or injury is of such a nature that failure to receive immediate medical care could result in:- Serious jeopardy of the patient’s health
- Serious impairment to bodily functions
- Serious dysfunction of any bodily organ or part
- Serious disfigurement; or
- Serious jeopardy to the health of the fetus, in the case of a pregnant patient
Access standards for hours of operation- Hours of operation of the Medicare Advantage organization’s providers are convenient to, and do not discriminate against members
- Services are available to members 24 hours a day, seven days a week
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Specialty care access standards
Commercial specialty care for practitionersAppointment availability Outpatient referral and consultation Within 21 calendar days Scheduled follow-up outpatient visits Consistent with the clinical need
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Behavorial health and substance use access standards
Commercial behavioral health and subsance use care
Appointment availability Life-threatening emergency Available and accessible (24-hour availability with qualified on-call coverage) for life-threatening and non-life-threatening emergencies Non-life-threatening emergency Within six hours or refer to emergency room Urgent or emergency care Immediately or refer to emergency room Routine Within seven business days Routine follow-up Within 30 business days
Medicare Advantage behavioral health and substance use careAppointment availability Urgent or emergency care Immediately or directed to ER Symptomatic, non-urgent care Within seven business days Routine, preventative care Within 30 business days
Emergency medical conditions are medical conditions of a recent onset and severity, including but not limited to severe pain, that would lead a prudent layperson possessing an average knowledge of medicine and health to believe that his or her condition, sickness or injury is of such a nature that failure to receive immediate medical care could result in:- Serious jeopardy of the patient’s health
- Serious impairment to bodily functions
- Serious dysfunction of any bodily organ or part
- Serious disfigurement; or
- Serious jeopardy to the health of the fetus, in the case of a pregnant patient
Access standards for hours of operation- Hours of operation of the Medicare Advantage organization’s providers are convenient to and do not discriminate against members
- Services are available to members 24 hours a day, seven days a week