Anthem’s 24/7 Access Standards for Primary Care Physicians

Ensuring 24/7 Access: Anthem’s Standards for Physician Availability 

Providing continuous access to healthcare is a core responsibility for primary care physicians (PCPs). Anthem has set clear standards to ensure that members can reach their PCPs around the clock and receive timely medical care when needed. Below is an overview of the key requirements for physician access and appointment availability. 

24/7 Access Requirements 

To meet Anthem’s standards, PCPs must be accessible to their patients 24 hours a day, 7 days a week. This means: 

• An answering machine alone does not qualify as proper access. 
• PCPs must provide clear information on their regular office hours and after-hours care procedures. 
• When unavailable, PCPs must arrange for a designated back-up physician from the same network to provide care. 

The back-up physician must be a comparably trained practitioner, ensuring that patients receive appropriate care. For example: 

• Family Practice and General Practice physicians can provide mutual coverage. 
• Internal Medicine specialists can be backed up by other internists or family practitioners. 
• Pediatricians must arrange for coverage with another pediatrician or a family practice physician. 

Additionally, back-up physicians must document all medical services provided and communicate relevant details to the patient’s primary doctor. 

Handling Urgent Situations 

If a member is out of the area and needs urgent or emergency care, they are instructed to contact their PCP. If that is not possible, they may reach out to the designated back-up physician. Anthem monitors compliance with these access standards through annual audits. 

Compliance criteria include: 

• A live person must answer within two calls. 
• If an answering service is used, it must confirm its association with the physician and provide a means of direct contact. 
• Messages should not direct patients to the ER unless it is a true emergency. 

Appointment Availability Standards 

Anthem has also established minimum requirements for scheduling patient appointments. These include: 

 

                          

PCPs treating HMO and POS members must be available in-office for at least 16 hours per week per location. Additionally, patients should not wait more than 15 minutes past their scheduled appointment time without an explanation or the option to reschedule. 

Physician Responsibilities 

All participating providers must adhere to Anthem’s access and appointment availability standards. Other key responsibilities include: 

• Complying with managed care requirements where applicable. 
• Submitting claims accurately and not balance billing members for covered services. 
• Ensuring that all patients receive care without discrimination. 
• Not discouraging patients from providing feedback through Anthem’s surveys. 

HMO Physician Requirements 

Physicians in Anthem’s HMO-based networks have additional obligations, particularly PCPs who serve as healthcare coordinators. These responsibilities include: 

• Being accessible 24/7 and arranging appropriate back-up coverage. 
• Coordinating or providing all care for HMO members. 
• Issuing referrals to specialists as required by the member’s benefit plan. 

Maintaining Quality Care 

Anthem monitors physician compliance through on-site visits, appointment book reviews, member satisfaction surveys, and complaint evaluations. By upholding these standards, PCPs play a critical role in ensuring that patients receive timely, high-quality care whenever they need it. 

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