CurrentAnthemPolicy N/A

Timely access to outpatient mental health and substance use services

Describes member rights and plan obligations for appointment wait-time standards, complaint procedures, and temporary referrals to out-of-network providers when timely in-network appointments are unavailable; applies to Anthem Blue Cross and Blue Shield HP members covered under the referenced plan.

Policy Summary

PayerAnthem

PolicyTimely access to outpatient mental health and substance use services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionIf no in-network provider can meet the wait-time standards, request a service complaint by calling 1-800-300-8181 (TTY 711) to obtain an approved referral to a non-contracted provider at in-network cost-sharing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

10 business daysmax wait — initial outpatient MH

7 calendar daysmax wait — post-discharge/ED

3 business daysplan response time after complaint

1-800-300-8181assistance phone line

Up to $200/yrActive&Fit fitness reimbursement

Timely Access & Temporary Out-of-Network Referral

Timely Access and Temporary Out-of-Network Referral

Covered when the plan's access standards and referral process are followed:

Access standards: Member must be offered an appointment with a contracting provider within 10 business days for an initial outpatient mental health or outpatient substance use appointment, and within 7 calendar days after a discharge or emergency department visit.10 business days; 7 calendar days

Appointments may be via telehealth unless the member requests an in-person visit.

Plan response to complaint: If no contracting provider is available within the required wait time, member or designee may file a service complaint by calling 1-800-300-8181 (TTY 711) or submitting a written complaint; the plan has 3 business days to locate a contracting provider who can meet the requirements. If none is found, the plan will notify the member and approve a referral to a non-contracted provider at in-network cost-sharing until an appropriate contracting provider is available or the referral is terminated.3 business days

Policy Summary

PayerAnthem

PolicyTimely access to outpatient mental health and substance use services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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Approved non-contracted providers must be able to treat the condition, meet wait-time requirements, be within a reasonable distance for in-person visits if requested, and have reasonable charges.

Referral to a non-contracted provider will terminate when one of the following occurs: the services are determined to be no longer medically necessary, or the plan identifies a contracting provider who can assume care. For an in-network transfer to end the out-of-network referral, the contracting provider must be able to treat the member’s mental health or substance use condition, meet the required appointment wait times, be within a reasonable distance if the member requests an in-person visit, and be able to receive a transfer of care without causing harm. Members remain responsible only for applicable in-network cost sharing while the approved non-contracted referral is in effect.

Provider & Member Steps for Complaints and Referrals

Prior Authorization

Referral termination when services are no longer medically necessary

If services previously approved under an out-of-network referral are later determined to be no longer medically necessary, the approved referral will be terminated and Anthem will no longer authorize or reimburse those services. Providers should discontinue scheduling or delivering services that are no longer medically necessary and follow standard notification and utilization review procedures.

Referral ends when services are no longer medically necessary.
Providers must stop providing services when authorization is withdrawn and follow Anthem notification/utilization review requirements.

Note

Not applicable

Not applicable / no additional specification in this section.

Note

Member contact requirements to request assistance

If you or your authorized representative cannot find an in-network provider who can meet the appointment wait-time standards, contact Anthem for assistance. Call 1-800-300-8181 (TTY 711) or submit a written complaint to Anthem, PENN 1, 35th Floor, New York, NY 10119 to request help locating a provider or to request an out-of-network referral at in-network cost when timely access standards are not met.

Call 1-800-300-8181 (TTY 711) for assistance.
Or submit a written complaint to Anthem, PENN 1, 35th Floor, New York, NY 10119.

Billing Rule

Out-of-network referral when timely access unavailable

When no contracted provider can meet the wait-time or distance standards, Anthem may approve a referral to a non‑contracted provider at in‑network cost sharing. Approved referrals will only be granted if the non‑contracted provider can treat the condition, meet wait‑time standards, be within a reasonable distance if an in‑person visit is requested, and charge reasonable fees.

Non-contracted referral approved when no in-network provider meets wait-time/distance standards.
Non-contracted provider must be able to treat the condition, meet wait-time requirements, be within reasonable distance for in-person visits, and have reasonable charges.

Key Definitions

Service complaint — definition and applicable context

TermService complaint

DefinitionA complaint filed when you cannot obtain services from a contracting provider within the required appointment wait time.

ContextUsed when members request outpatient mental health or outpatient substance use services and cannot secure an in-network appointment within the plan's wait-time standards.

Appointment waiting time — definition of wait-time calculation for outpatient mental health/substance use services

TermAppointment waiting time

DefinitionThe time from the initial request for outpatient mental health or outpatient substance use services to the earliest available appointment.

ApplicabilityApplies to scheduling initial outpatient mental health or outpatient substance use appointments and follow-up scheduling requirements under the plan's timely-access standards.

Outpatient Level-of-Care

Wellness & Fitness Reimbursement

Wellness / Fitness Reimbursement

Active&Fit fitness reimbursement: Members may receive reimbursement for fitness through Active&Fit by joining a network gym and meeting workout frequency and reimbursement submission rules; up to $200 per year (up to $100 per eligible six-month period) with 50 workouts required per six-month period for some reimbursements.50 workouts per 6 months; up to $200/year

See benefits table for eligibility and submission details; join network gym and retain records for verification.

Service Visit and Program Requirements

workouts required for Active&Fit reimbursement — numeric requirement (50 workouts/6-month period)

ProgramActive&Fit fitness reimbursement

Workout requirement50 workouts per 6-month period

Reimbursement limitsUp to $100 per eligible six-month period (up to $200 per year)

SubmissionSubmit reimbursement receipts after each six-month period when using a non-network provider; in-network gym enrollment may not require submission as the gym maintains records.

Background and Scope

This policy addresses timely access standards and the member complaint and referral process for outpatient mental health and substance use services rather than clinical treatment guidance. It defines key terms such as service complaint and appointment wait time, specifies required maximum wait times for initial and post-discharge appointments, and describes the steps the plan will take if in-network access within those wait times is not available, including assistance via the designated contact line.