The Centers for Medicare and Medicaid Services’ revised guidelines for appointment availability and access should be followed to ensure timely access to medical care for Medicare Advantage members.
Under CMS’s Time Standards (42 CFR 422.112) the revised guidelines codify wait time standards to reflect business days instead of weekdays.
CMS applies these standards to primary care and behavioral health services and substance use disorder services as follows.
- Routine and preventive care within 30 business days
- Urgent, but non-emergent care within 24 hours of request
- Services that are not emergency or urgently needed, but requires medical attention — within seven business days (revised from one week)
Note: as documented in our BCBSNM Provider Reference Manual, our providers are held to an access standard for all BCBSNM members to create consistency and simplify compliance. This access standard meets or exceeds the access standard for all members, including the new Medicare access update. These standards are available in the BCBSNM Provider Reference Manual section 4.2.8 for Primary Care Physicians and 4.3.4 for Specialist and Behavioral Health Access Standards.
For more information refer to CMS’s Access to Services (42 CFR 422.112).