Access Standards - Health Plan of San Joaquin

Mandatory Appointment Availability Standard

After-Hours
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.

After-Hours Access Survey & Questions

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.

Here is an overview:

To pass the survey, all (4) questions listed in the After-Hours Access table needed to be answered with a “Y”.
Those provider offices that received at least one “N,” received a “non-passing” score and are required to adjust their messaging process and messaging content to be fully compliant.
Notification letters are sent out informing the provider office of any questions areas that may have failed the survey.
Sites that are identified with non-passing scores will be resurveyed to verify that their after-hours messaging meets all Medi-Cal compliance points.

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?

Appointment Access Standards for Medi-Cal

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.