Provider Education: Only Licensed Personnel May Triage Medi-Cal Patients

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Date: July 23, 2021
To: Medi-Cal Providers
From: Health Plan of San Joaquin
Subject: Provider Education: Only Licensed Personnel May Triage Medi-Cal Patients
Business: Medi-Cal Managed Care

HPSJ monitors accessibility within our network to ensure providers are available for appointments within the standards for timely access formed by the Department of Managed Health Care and Department of Health Care Services. Please be aware, California’s Timely Access Standards and Wait Times Set specifies that only licensed health care personnel are permitted to triage or screen Medi-Cal patients to assess urgency of need for care.

Appropriately licensed personnel for triaging the health concerns of an HPSJ member include a licensed physician, registered nurse (RN), certified nurse midwife (CNM), nurse practitioner (NP), physician assistant (PA), and other licensed personnel acting within their scope of practice to screen patients.

Unlicensed personnel are NOT eligible to triage or screen Medi-Cal patients –
Unlicensed personnel who process patient phone calls or unscheduled office visits may ask questions on behalf of appropriately licensed health care personnel for the purpose of determining a patient’s condition. However, unlicensed personnel shall not use a patient’s responses to assess, evaluate, or determine the urgency of the patient’s need for care.

Real World Examples –

  • A Licensed Vocational Nurse (LVN) may perform observation and data collection for basic physical assessment, but they shall not perform any part of the triage process that includes the independent evaluation, data interpretation, and determination of a patient’s treatment priorities or levels of care. (California Board of Vocational Nursing & Psychiatric Technician Examiners)
  • A receptionist who is not a licensed health care professional may inquire about a patient’s condition, but they shall not independently screen a patient’s health concerns to determine the urgency of the patient’s need for care. For instance, if an HPSJ member presents with a fever, the receptionist cannot assess whether the patient medically requires prompt attention from a provider. This determination must be made by appropriately licensed personnel.
  • Other unlicensed personnel, such as a medical assistant, may collect patient information only as authorized by a physician

Thank you for being our partner –
HPSJ aims to support your clinical or medical office management in the provision of appropriate, coordinated health care services. Clinical partners who appropriately follow established procedures, including the Timely Access Standards and Wait Times Set, are
essential to the provision of quality health care for HPSJ members.

If you have questions regarding this important subject, please contact your HPSJ Provider Services Representative or call our Customer Service Department at 209.942.6320.

Posted on July 23rd, 2021