CMA obtains clarification on Blue Cross timely access contract amendment

December 12, 2010
Area(s) of Interest: Payor Contracting Payor Issues and Reimbursement 

The California Medical Association (CMA) recently received a number of calls from physicians concerned about a new Blue Cross contract amendment. According to a notice mailed to physicians in October, the amendment was issued to ensure compliance with the Department of Managed Health Care's "timely access" regulations, which take effect Jan. 17, 2011.

The regulations require health plans regulated by DMHC to ensure that patients can see a provider within certain time frames and that plans have adequate provider networks to meet these requirements.

CMA's review of the amendment determined that it included a number of provisions that appeared to go beyond the timely access regulatory parameters. CMA raised its concerns with the insurer, specifically with regard to the "in-office waiting room time," "emergency care" and "member services by telephone" sections of the amendment. in response to CMA's concerns, Blue Cross has provided the following clarifications:

  • In-office waiting room time - the original notice indicated that "in-office waiting room time" was part of the timely access requirements. Blue Cross has clarified that this is an existing Anthem Blue Cross requirement and is not related to the new timely access regulation.
  • Emergency care - the original notice stated that physicians were required to provide "immediate access to emergency care." Blue Cross has since clarified that after-hours answering service staff and answering machine instructions should direct patients in the event of an emergency to call 911 or go to the emergency room.
  • Member services by telephone - the original notice also said that patients must be able to reach a live person within 10 minutes during normal business hours. Blue Cross has since clarified that this is a plan responsibility and not a physician responsibility.

Many health plans and medical groups/IPAs, including Blue Cross, already require physicians to meet specific access standards. Physicians contracting with Blue Cross should note that the new state-mandated timely access time frames are less stringent than Blue Cross' existing requirements as specified in Section 4.2 of the standard Prudent Buyer contract. 

For more information, see the November issue of Blue Cross' Network Update.

Contact: CMA's reimbursement help line, 888/401-5911 or economicservices@cmadocs.org.



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