Mandatory Appointment Availability Standard
- Routine Care
- Urgent Care
Health Plan of San Joaquin (HPSJ) is charged with maintaining the quality of care for our members. We must monitor access and availability within the network, making sure access standards are observed by contracted providers and any deficiencies are addressed. These access standards are set forth by both the Department of Health Care Services (DHCS) and the Department of Managed Health Care (DMHC), with the exception of in-office wait times—those in-office wait times are set and monitored by HPSJ.
Medi-Cal health plans are required to conduct a yearly After-Hours Access Survey with a sampling of our contracted provider offices. It is designed to help determine the level of access our Medi-Cal members have for urgent/emergent after-hours care throughout the network by testing the messaging content that provider offices use via answering service or through voicemail/messaging equipment and software.
The next survey period is scheduled in November, annually. Please be sure that your messaging has been updated to follow the requirements.
|After- Hours Access Survey Questions||Y/N|
|1) Is the practitioner’s answering system for after-hours urgent care/emergent physician coverage available 24 hours, 7 days a week?|
|2) Does the answering service or voice mail state the length of when a return call can be expected from the provider?|
|3) Are after-hours emergency instructions provided via answering machine and/ or direct communication via answering service?|
|4) Does the answering service or voice message specify a time in which the member should expect a return call?|
Members have the right to be scheduled for appointments within the following time frames :
|Types of Services||Standard|
|Access to non-urgent appointments or primary care – regular and routine care (with a PCP)||Within 10 business days of request|
|Access to non-urgent appointments for mental health (non-physician)||Within 10 business days of request|
|Access to urgent care services that do not require prior authorization||Wait time not to exceed 48 hours of request|
|Access to urgent care (specialist and other) services that require prior authorization||Wait time not to exceed 96 hours of request|
|Access to non-urgent appointments with a specialist||Within 15 business days of request|
|Access to after-hours care (with a PCP)||Ability to contact on-call physician after hours within 30 minutes for urgent issues|
|Access to preventive health services within 30 business days of request||Access to preventive health services within 30 business days of request|
|Non-urgent appointments for ancillary services for the diagnosis or treatment of injury||Within 15 business days of request|
|In-office wait time for scheduled appointments (PCP)||Not to exceed 45 minutes|
|In-office wait time for scheduled appointments (Specialists)||Not to exceed 60 minutes|
Per DMHC, non-physician mental health providers include counseling professionals, substance abuse professionals, and qualified autism service providers. Access the Timely Access to Care Fact Sheet by visiting the following URL: https://dmhc.ca.gov/Portals/0/Docs/DO/TAC_accessible.pdf
If you have questions, contact our Provider Services Department at 209.942.6340.
Posted on November 15th, 2021 and last modified on January 11th, 2023.top