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Access to Care Standards: Focusing on the Medicare Advantage Patient

Blue Cross and Blue Shield of North Carolina (BCBSNC) maintains access-to-care standards to ensure that our Medicare Advantage members receive timely access to quality health care and services.  Primary care physicians and specialists participating in BCBSNC’s Medicare Advantage networks should review and adhere to the following care access standards, and schedule appointments only within these timeframes for all BCBSNC Medicare Advantage patients.     

Emergent/life-threatening situations should be referred directly to the closest emergency department or to 911.  It is not necessary to see the patient first in the office for these situations.

Guidelines for BCBSNC Primary Care Physicians

Waiting time for appointments (number of days):

            (A)  Urgent - not life threatening, but a problem needing care within

                    24 hours

Pediatrics

see within 24 hours

Adults

see within 24 hours

         (B)  Symptomatic non-urgent (e.g., cold, no fever)

Pediatrics

within 3 calendar days

Adults

within 3 calendar days

         (C)  Follow-up of urgent care           

Pediatrics

within 7 days

Adults

within 7 days

        (D)  Chronic care follow-up (e.g., blood pressure checks, diabetes checks)

Pediatrics

within 14 days

Adults

within 14 days

          (E)  Complete physical/health maintenance

Pediatrics

within 30 calendar days

Adults

within 60 calendar days

Guidelines for BCBSNC Physician Specialists

Waiting time for appointment (number of days):

            (A)  Urgent - not life threatening, but a problem needing care within

                   24 hours

Pediatrics

within 24 hours

 

Adults

within 24 hours

 

         (B)  Regular care

Pediatrics

(e.g., tube referral) - within 2 weeks

 

Adults

Sub-acute problem of short duration—see within 2 weeks

Chronic problem (needs long time for consultation)--see within 4 weeks

These access-to-care standards apply to specialists including: MD ophthalmologists, obstetrician/gynecologist, and non-MD specialists, such as optometrists, chiropractors, podiatrists, physical therapists, speech therapists, and occupational therapists.

Guidelines for BCBSNC Behavioral Health Providers

Waiting time for appointment:

Life –Threatening Emergency

See immediately

Non-life Threatening Emergency

See within six hours

Urgent Care

See within 48 hours

Routine Office Visit

See within 10 working days

 If you have any questions, please contact the Provider Blue LineSM at 1.800.214.4844.