Timely Access to Care
Health Plans in California must ensure that members have timely access to their physicians and other providers when seeking care. This means that there are limits on how long members have to wait to get an appointment and telephone advice. The wait times are shown in the chart below. Some exceptions to the wait times apply. Sometimes waiting longer for care is not a problem. You may give a member a longer wait time if you determine it would not be harmful to the member’s health. In this event, you must note in the member’s record that a longer wait time will not be harmful to their health. If Members have questions that you are not able to answer, please direct them to Community Care Health’s Member Services Department at (855) 343-2247.
Other Regulatory Requirements:
After Hours Care:
|Emergency Care (life threatening)
||Seek immediate care at the nearest hospital
|Urgent Care (non-life threatening) – no prior authorization required
||Appointment is offered within 48 hours from time of the request
|Urgent Care (non-life threatening) – prior authorization required
||Appointment is offered within 96 hours from time of the request
|Non-urgent appointments with a primary care physician (PCP) for regular and routine primary care services
||Appointment is offered within 10 business days from time of the request
|Non-urgent care appointments with a specialist
||Appointment is offered within 15 business days from time of the request
|Non-urgent appointment with a mental health provider (who is not a physician)
||Appointment is offered within 10 business days from time of request
|Non-urgent appointments for ancillary services for the diagnosis or treatment of an injury, illness or other heath condition
||Appointment is offered within 15 business days from time of request
|Telephone triage and advice*
||No greater than 30 minutes
Members should be able to reach a recorded message or live voice response providing emergency instructions and for non-emergent (urgent) matters information when to expect to receive a call back.
Providers should instruct their after-hours answering service staff that if the caller is experiencing an emergency, the caller should be instructed to dial 911 or to go directly to the nearest emergency room. Answering machine instructions must also direct the member to call 911 or go the nearest emergency room if the caller is experiencing an emergency.