Mental health and substance use network access and related plan updates
Governs appointment wait time standards, access complaint process and referrals to non-participating providers for outpatient mental health care and outpatient substance use services; also includes several plan benefit updates affecting members.
No material clinical or coverage changes in this revision.
Coverage Criteria for Outpatient Mental Health and Substance Use Services
Access Complaints, Referrals, and Provider Responsibilities
Access Complaint and 3‑Day Referral Process
If no Participating Provider is available within the required Appointment Wait Time, the member or their designee may submit an Access Complaint by calling 1-800-300-8181 (TTY 711) or in writing to Anthem, PENN 1, 35th Floor, New York, NY 10119. Upon receipt, Anthem has three (3) business days to locate a Participating Provider who can treat the condition, meet the Appointment Wait Time, and (if an in-person visit is requested) is within a reasonable distance; if Anthem cannot locate such a provider they will notify the member and approve a referral to a Non‑Participating Provider at In‑Network Cost‑Sharing.
- Submission methods: phone 1-800-300-8181 (TTY 711) or written to Anthem, PENN 1, 35th Floor, New York, NY 10119.
- Insurer timeframe: 3 business days to locate a Participating Provider who can treat the condition, meet the Appointment Wait Time, and be within reasonable distance for in-person visits.
- If unsuccessful, Anthem will notify the member (by phone if the request was by phone, and in writing) and approve a referral to a Non‑Participating Provider at In‑Network Cost‑Sharing provided the Non‑Participating Provider can treat the condition, meet the wait time, is within reasonable distance if in‑person requested, and does not charge excessive or unreasonable rates.
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