Guidelines for timely member access to health care professionals

Blue Cross has established guidelines to ensure members have appropriate and timely access to their health care providers; we’ll conduct annual provider surveys to assess compliance with these quality indicators.

Primary care

• Regular and routine care – within 30 business days of member request
• Urgent care – within 48 hours of member request
• After-hours care – 24 hours a day, seven days a week through at least one of the following methods:

• Answering service (with live operator rather than a messaging system)
• On-call pager (call must be returned within 30 minutes)
• Call forwarding to a number where the covering practitioner can be reached
• Recorded telephone message that directs member to a physician for after-hours care

Behavioral health care

• Not life-threatening emergency – within six hours of member request
• Urgent care – within 48 hours of member request
• Initial visit for routine care – within 10 business days of member request
• Follow-up routine care – within 30 days of member request

Specialty care

• High-volume specialist: Obstetrician-gynecologist
• Regular and routine care – within 30 business days of member request
• Urgent care – within 48 hours of member request
  
  
• High-impact specialist: Oncology
• Regular and routine care – within 30 business days of member request
• Urgent care – within 48 hours of member request
  

For more detailed information, see the Access Standards in the PPO Policies chapter of your provider manual on web-DENIS, or contact your provider consultant.