DMHC Access Standards
Department of Managed Health Care (DMHC)
Timely Access to Care Standards
Heritage Provider Network, Inc. / Regal Medical Group, Inc. / Lakeside Community Healthcare/ ADOC Medical Group / Greater Covina Medical Group, Inc. has established compliance policies across all lines of our business, to ensure timely access to care for our members and patients.
These standards are based upon state, federal, and NCQA access and availability standards. These standards specifically include, but are not limited to California Department of Managed Health Care (DMHC) Timely Access to Care Standards.
According to the California Department of Managed Health Care, state law and regulations requires health plans to provide timely access and availability to care to all members. Legally, there are time limits to how long members may be required to wait to receive healthcare appointments and/or telephone consultations.
As providers, we must take a proactive approach to ensure our members receive the proper care in a timely and accessible manner as governed by the laws and regulations of state and federal and contractual requirements imposed upon us. Please review the following excerpts from our Company’s Policy and Procedure (QI-006) that incorporates and reviews access and availability requirements, including those of the California Department of Managed Health Care.The complete policy and procedure can be viewed by clicking this link .
Allowable wait times for appointments:
Commercial non-emergent medical appointment access standards
| Appointment type | Time-elapsed standard |
|---|---|
| Non-urgent care appointments for primary care (PCP) | Must offer the appointment within 10 Business Days of the request |
| Non-urgent care appointments with specialist physicians (SCP) | Must offer the appointment within 15 Business Days of the request |
| Urgent care appointments that do not require prior authorization (PCP) | Must offer the appointment within 48 hours of request |
| Urgent care appointments that require prior authorization | Must offer the appointment within 96 hours of request |
| Non-urgent care appointments for ancillary services (for diagnosis or treatment of injury, illness, or other health condition) | Must offer the appointment within 15 Business Days of the request |
Medi-Cal non-emergent medical appointment access standards
| Access measure | Time-elapsed standard |
|---|---|
| Access to PCP or designee | 24 hours a day, 7 days a week |
| Non-urgent care appointments for Primary Care (PCP) | Must offer the appointment within 10 business days of request |
| Regular and routine, excludes physicals and wellness checks | Must offer the appointment within 10 business days of request |
| Adult physical exams and wellness checks | Must offer the appointment within 30 calendar days of request |
| Non-urgent appointments with specialist physicians (SCP regular and routine) | Must offer the appointment within 15 business days of request |
| Urgent care appointments that do not require prior authorization (includes appointment with any physician, Nurse Practitioner, Physician’s Assistant in office) | Must offer the appointment within 48 hours of request |
| Urgent care appointments that require prior authorization (SCP) | Must offer appointment within 96 hours of request |
| First prenatal visit | Must offer the appointment within 2* weeks of request |
| Well child visit | Must offer the appointment within 10 business days of request |
| Non-urgent appointments for ancillary services (diagnosis or treatment of injury, illness, or other health condition) | Must offer the appointment within 15 business days of request |
| Initial health assessment (enrollees age 18 months and older) | Must be completed within 90 calendar days of enrollment |
| Initial health assessment (enrollees age 18 months and younger) | Must be completed within 60 calendar days of enrollment |
Centers for Medicare & Medicaid Services (CMS)
Emergent & non-emergent appointment access guidelines
| Appointment type | Time-elapsed standard |
|---|---|
| Medically necessary services | Must be made available 24 hours a day, 7 days a week |
| Urgently needed services or emergency room | Immediately |
| Services that are not emergency or urgently needed, but in need of medical attention | Within one week |
| Routine and preventive care | Within 30 days |
Behavioral health emergent & non-emergent appointment access standards
| Appointment type | Time-elapsed standard |
|---|---|
| Non-urgent appointments with a physician behavioral health care provider (psychiatrist) | Must offer the appointment within 15 business days of request |
| Non-urgent care appointments with a non-physician behavioral health care provider 1 | Must offer the appointment within 10 business days of request |
| Appointment for follow-up routine care with a non-physician behavioral health care provider (i.e. psychologists, Licensed Clinical Social Workers (LCSW), Marriage and Family Therapists (MFT)1 | Members have a follow-up visit with a non- physician behavioral health care provider within twenty (20) calendar days of initial visit for a specific condition |
| Urgent care appointments | Must offer the appointment within 48 hours of request |
| Access to care for non-life threatening emergency | Within 6 hours |
| Access to life-threatening emergency care | Immediately |
| Access to follow up care after hospitalization for mental illness | Must provide both: One follow-up encounter with a mental health provider within 7 calendar days after discharge. Plus one follow-up encounter with a mental health provider within 30 calendar days after discharge. |
Exceptions:
Preventive care services and periodic follow up care:
Preventive care services and periodic follow up care including but not limited to, standing referrals to specialist for chronic conditions, periodic office visits to monitor and treat pregnancy, cardiac or mental health conditions, and laboratory and radiological monitoring for recurrence of disease, may be scheduled in advance consistent with professionally recognized standards of practice as determined by the treating licensed health care provider acting within scope of his or her practice.
Advance access:
A primary care provider may demonstrate compliance with the primary care time-elapsed access standards established herein through implementation of standards, processes and systems providing advance access to primary care appointments as defined herein.
Appointment rescheduling:
When it is necessary for a provider or enrollee to reschedule an appointment, the appointment shall be promptly rescheduled in a manner that is appropriate for the enrollee’s health care needs, and ensures continuity of care consistent with good professional practice and consistent with the objectives of this policy.
Extending appointment waiting time:
The applicable waiting time for a particular appointment may be extended if the referring or treating licensed health care provider, or the health professional providing triage or screening services, as applicable, acting within the scope of his or her practice and consistent with professionally recognized standards of practice, has determined and noted in the relevant record that a longer waiting time will not have a detrimental impact on the health of the enrollee as required by section 1300.67.2.2 (5)(g) of the California Health and Safety Code of Title 28 of the California Code of Regulations.
Telemedicine:
To the extent that telemedicine services are appropriately provided as defined per Section 2290.5(a) of the Business & Professions Code, these services shall be considered in determining compliance with the access standards hereby established. Prior to the delivery of health care via telemedicine, the provider must obtain verbal and written informed consent from the enrollee or the enrollee's legal representative. The informed consent procedure shall ensure that at least all of the following information is given to the enrollee or the enrollee's legal representative verbally and in writing:
- The enrollee or the enrollee's legal representative retains the option to withhold or withdraw consent at any time without affecting the right to future care or treatment nor risking the loss or withdrawal of any program benefits to which the enrollee or the enrollee's legal representative would otherwise be entitled.
- A description of the potential risks, consequences, and benefits of telemedicine.
- All existing confidentiality protections apply.
- All existing laws regarding enrollee access to medical information and copies of medical records apply.
- Dissemination of any enrollee identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without the consent of the enrollee.
An enrollee or the enrollee's legal representative shall sign a written statement prior to the delivery of health care via telemedicine, indicating that the enrollee or the enrollee's legal representative understands the written information provided and that this information has been discussed with the healthcare practitioner, or his or her designee. The written consent statement signed by the enrollee or the enrollee's legal representative shall become part of the enrollee's medical record.
1Examples of non-physician mental health providers include counseling professionals, substance abuse professionals and qualified autism service providers.
2Examples of non-urgent appointment for ancillary services include lab work or diagnostic testing, such as mammogram or MRI, and treatment of an illness or injury such as physical therapy.
Members who are experiencing a delay in care of have issues with access should contact the Help Center at (888) 466-2219, or visit HealthHelp.ca.gov.
For more detailed information on timely access to care, visit the DMHC website.
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