July 2017  

Appointment Availability and Access Guidelines for Blue Cross Community Centennial Members

As a contracted Blue Cross and Blue Shield of New Mexico (BCBSNM) provider for Blue Cross Community Centennial, the following appointment availability and access guidelines should be used to ensure timely access to medical and behavioral health care for our Blue Cross Community Centennial membership:

• Routine outpatient diagnostic laboratory, diagnostic imaging and other testing appointments – request-to-appointment time shall be consistent with the clinical urgency, but no more than 14 days unless patient requests a later time
• Outpatient diagnostic laboratory, diagnostic imaging and other testing – if a walk-in system, rather than an appointment system, is used the member wait time shall be consistent with the severity of the clinical need
• Urgent outpatient diagnostic laboratory, diagnostic imaging, and other testing – appointment availability shall be consistent with the clinical urgency, but no longer than 48 hours
• In-person prescription fill time (ready for pickup) shall be no longer than 40 minutes. A prescription phoned in by a practitioner shall be filled within 90 minutes
• For behavioral health crisis services, face-to-face appointments shall be available within two hours
• Sufficient transportation is available to meet the needs of the member
• New durable medical equipment (DME) and repairs to existing DME owned or rented by the member – approve or deny the request within seven working days of the request date.
  • All new customized or made-to-measure DME or customized modifications to existing DME owned or rented by the member shall be delivered to the member within 150 days of the request date.
  • All standard DME shall be delivered within 24 hours of the request, if needed on an urgent basis.
  • All standard DME not needed on an urgent basis shall be delivered within a time frame consistent with clinical need.
  • All DME repairs or non-customized modifications shall be delivered within 60 days of the request date.
  • The Manaqed Care Organization (MCO) shall have an emergency response plan for non- customized DME needed on an emergent basis

After-Hours Care
PCP offices are to communicate after-hours care either via an answering system or answering service to the member who calls for information and/or instructions as to how to obtain health care when the practitioner's office is closed.

The following after-hours information is to be communicated to the member:

• Current office hours (when to call back)
• Instructions on calling for an office appointment
• Information on how to access the on-call practitioner, as appropriate
• Instructions to call “911" or to go to the emergency room if patient is experiencing a life-threatening condition