Blue Review
A Medicaid Provider Newsletter

October 2017

After-hours Service Requirements

Blue Cross and Blue Shield of Texas (BCBSTX) plan members have access to quality, comprehensive health care services 24 hours a day, seven days a week. This means members can call their primary care provider (PCP) with a request for medical assessment after normal PCP office hours. The PCP must have an after-hours system in place to help ensure members can reach either him or her, or an on-call physician with medical concerns or questions. After-hours service requirements include:

  • The initial recording and answering service must have an interpreter, or English and Spanish capabilities.
  • An answering service or after-hours personnel must forward member calls directly to the PCP or on-call physician, or instruct the member that the provider will contact them within 30 minutes of their call.
  • The answering service or after-hours personnel must ask the member if the call is an emergency. In the event of an emergency, they must immediately direct the member to dial 911 or to proceed directly to the nearest hospital emergency department (ED).
    • If staff or an answering service is not immediately available, an answering machine may be used, but it is required to instruct members with emergency health care needs to dial 911 or go directly to the nearest hospital ED.
    • Further answering machine instructions are required to direct members to an alternative contact number so they can reach the PCP or an on-call provider with medical concerns or questions.

Contract Standards
BCBSTX monitors providers’ appointment availability and after-hours availability to ensure members receive timely access to quality care and to ensure compliance with the Health and Human Services Commission standards. As an in-network provider, you may receive an annual request to demonstrate compliance with this contract standard. Providers who do not meet the standards will receive written notification of the non-compliance from a BCBSTX medical director, and then will be resurveyed. If the provider continues to be noncompliant, corrective action may be taken to address the issue(s).

BCBSTX prefers that PCPs use plan-contracted, in-network physicians or other professional providers for on-call services. When that is not possible, PCPs must use their best efforts to help ensure that out-of-network on-call physicians or other professional providers abide by the terms of the BCBSTX provider contract.

Unacceptable After-hours Coverage 
BCBSTX outlines unacceptable after-hours coverage as:

  • The office telephone is only answered during office hours.
  • The office telephone is answered after hours by a recording instructing patients to leave a message.
  • The office telephone is answered after hours by a recording that directs patients to the ED for any services needed.
  • Returning after-hours calls past 30 minutes of when the call was received.

24/7 Nurseline
Members can also call the 24-hour Nurse Advice Line to speak to a registered nurse. Nurses can provide health information regarding illness and options for accessing care, including emergency services if appropriate.

Non-English Speaking Members
Non-English speaking members who call their PCP after hours can expect to receive language appropriate messages with appropriate care instructions. These instructions direct the member to dial 911 or to proceed directly to the nearest hospital ED in the event of an emergency. In a non-emergency situation, members will receive instructions on how to contact the on-call provider. If an answering service is used, the service should know where to contact a telephone interpreter for the member. All calls answered by an answering service must be returned.

BCBSTX monitors PCP compliance with after-hours access standards on a regular basis. Failure to comply with after-hours access standards may result in corrective action.