Administrative Policy Updates: Appointment Availability Access Standards

For 2020, Horizon BCBSNJ has revised certain administrative policy guidelines related to appointment availability access standards as they pertain to patients enrolled in State Health Benefits Program (SHBP)/School Employees’ Health Benefits Program (SEHBP) plans.

Below is an excerpt of the update to our Appointment Availability Access Standards for Primary Care-Type Providers, ObGyns and Specialists.

Appointment Availability Access Standards for Primary Care-Type Providers, ObGyns and Specialists

For Routine Physical Exams, including annual health assessments, as well as routine gynecological physical exams for new and established patients:

• Except as set forth below, the practitioner shall offer Horizon BCBSNJ members a scheduled appointment as soon as possible, but not to exceed four months of the request.

  New for 2020: Practitioner shall offer a SHBP/SEHBP member a scheduled appointment as soon as possible, but not to exceed eight weeks of the request.

  Horizon BCBSNJ recognizes that the Centers for Medicare & Medicaid Services (CMS) recommends a stricter guideline for preventive care and will monitor response rates to ensure that the majority of our practitioners offer an appointment within a 30 day time period.

Below is an excerpt of the update to our Behavioral Health Provider Access Standards

For Urgent Care, which includes any request for behavioral healthcare or treatment which in the opinion of a practitioner with knowledge of the enrollee’s behavioral health condition, would subject the enrollee to severe pain or distress that cannot be adequately managed without the care or treatment that is the subject of the request.

• Except as set forth below, the behavioral health practitioner shall offer the member a scheduled appointment within 48 hours of the request.

  New for 2020: The behavioral health practitioner shall offer the SHBP/SEHBP member a scheduled appointment within 24 hours of the request.

We thank you for your continued compliance with our appointment availability access standards and for the care you provide to our members.

Horizon BCBSNJ maintains appointment availability access standards for Primary Care Physicians (PCPs), obstetricians and gynecologists (Ob/Gyns), specialists and behavioral health care professionals to help ensure that our members receive care when they need it.

• Appointment Availability Access Standards for Primary Care-Type Providers, ObGyns and Specialists
• Behavioral Health Provider Access Standards

We strongly encourage you to review these standards and keep them in mind when offering your patients a first available appointment, responding to after-hours calls for urgent or emergent care, or monitoring office-waiting time.

This information, in addition to being available on our Administrative Policies page, may also be reviewed within our Participating Physician and Other Health Care Professional Office Manual.

Access Standard information is also available to our members.