Timely Access to Care

Balance is committed to ensuring that our members have timely access to the care they need. We adhere to specific timeframes to guarantee that appointments with providers are available within reasonable periods. These standards are in place to provide prompt medical attention and maintain the health and well-being of our members.

Appointment Timeframes

Balance will provide information to members and providers regarding the standards for timely access to care at least once a year. Information provided includes but is not limited to appointment wait times for urgent care, non-urgent primary care, non-urgent specialty care, and telephone screenings.

Timely access standards:

• Urgent care appointments not requiring prior authorization: within 48 hours
• Urgent care appointments for services requiring prior authorization: within 96 hours
• Non-urgent appointments for primary care: within 10 business days
• Non-urgent appointments with specialists: within 15 business days
• Non-urgent appointments with non-physician mental health care providers: within 10 business days
• Non-urgent appointments for ancillary services for the diagnosis or treatment of injury, illness, or other health conditions: within 15 business days
• Telephone triage waiting time not to exceed 30 minutes
• Balance shall offer follow-up appointments with a non-physician mental health care or substance use disorder provider within ten (10) business days of the prior appointment for members undergoing a course of treatment for an ongoing mental health or substance use disorder condition.
  • Balance will not limit coverage for non-urgent follow-up appointments with a non-physician mental health care or substance use disorder provider to once every ten (10) business days.
• Non-urgent appointments with a non-physician mental health care or substance use disorder provider will be offered within ten (10) business days of the request for an appointment.

Interpreter Services

Interpretation services are provided through Balance Member Services by phone or in person at no cost. If you need language assistance during your appointment, ask your Provider to arrange an Interpreter.

Distance

To ensure timely access to care, Balance requires:

• Primary Care Provider(PCP)/Hospital must be within 15 miles or 30 minutes from where the Balance member lives or works.
• You or your doctor may request out of network care when in-network providers are not available within 15 miles in distance or 30 minutes of travel time.

24/7 Nurse Advice Line

Balance provides or arranges for a licensed health care professional to be available to assist you by phone 24 hours a day, 7 days a week. You can reach a licensed health care professional by calling 1-888-243-8310.