Blue Cross Community Medicare-Medicaid PlanSM Availability and Access Standards

December 21, 2023

The following appointment availability and access guidelines should be followed by providers to ensure timely access to medical care for MMAISM members. These guidelines also apply to behavioral health services and substance use disorder services. 

  • Appointments for routine care, preventive care are available within five weeks from the date of request for such care.
  • Members with more serious problems not deemed emergency medical conditions shall be triaged and, if necessary or appropriate, immediately referred for urgent medically necessary care or provided with an appointment within one business day of the request.
  • Members with problems that are not deemed serious, but member requires medical attention shall be seen within seven business days.
  • Members with problems that are not deemed serious shall be seen within three weeks.
  • Appointment availability and access guidelines should be used to help ensure members have timely access to medical care. Below are the guidelines for appointments for obstetrics/gynecology:
    • First Trimester within two weeks
    • Second Trimester within one week
    • Third Trimester within three days

Adherence to member access guidelines will be monitored through Blue Cross and Blue Shield of Illinois office visits and the tracking of complaints and grievances related to access and availability, which are reviewed by the BCBSIL Quality Improvement Committee. 

Participating physician/professional providers are expected to provide coverage to members 24 hours a day, seven days a week. When a participating physician/professional provider is unable to provide services, the participating physician/professional provider must ensure that they have arranged for coverage from another participating physician/professional provider. Hospital emergency room or urgent care centers are not substitutes for covering participating physician/professional providers.