Access-to-Care Compliance Standards for Anthem Participating Providers

Anthem Access-to-Care Standards: Compliance Requirements and Monitoring 

Effective: December 1, 2025 | Applies to: All Anthem participating providers 

Anthem has reinforced contractual obligations for timely member access to care across all provider categories. The payer monitors compliance through third-party vendor accessibility audits (phone and electronic testing), member grievance analysis, and satisfaction surveys. 

Primary Care Provider Requirements 

Service Type - Required Timeframe 

Preventive care - 30-60 days (varies by state) 

Urgent care (acute symptoms) - Within 24 hours 

Routine check-ups - Within 10 business days 

After-hour access - 24/7/365 coverage required 

*State-specific preventive care timeframes: 30 days (CO, IN, KY, NV, OH, WI); 45 days (CT, ME, NH); 60 days (GA, MO, NV, VA) 

Specialty Care Requirements 

Currently applies to OB/GYN and oncology, with potential expansion to additional specialties: 

• Urgent care (acute symptoms): Within 24 hours 
• Routine check-ups: Within 30 calendar days 

Behavioral Health Requirements 

Service Type - Required Timeframe 

Non-life-threatening emergency - Within 6 hours 

Urgent services - Within 2 hours 

Initial routine services - Within 10 business days 

Follow-up routine services - Within 30 calendar days 

Post-discharge follow-up (HEDIS) - Within 7 calendar days 

After-hours access - 24/7/365 coverage required 

After-Hours Coverage Compliance 

Compliant: Live attendant or recording directing members to urgent care, 911, ER, or on-call physician with option to contact physician directly (transfer, cell, pager, text, email) or request callback. 

Non-compliant: Voicemail/answering machine that only refers members to ER or instructs them to call 911 without providing alternative pathways to care. 

Action Required 

• Review scheduling protocols against state-specific and service-type requirements 
• Audit after-hours messaging systems for compliance 
• Train front desk staff on access standard timeframes 
• Document capacity issues preventing compliance for Anthem review 
• Access full standards at https://anthem.com/provider 

Practices routinely failing to meet standards must document reasons (seasonal demand, specialty-specific challenges, capacity constraints) to demonstrate good-faith compliance efforts. 

Questions? Contact your Anthem network representative or refer to your Participating Provider Agreement. 

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