Access to Care Standards
Providers are required to conform to the Access to Care appointment standards to ensure that healthcare services are provided in a timely manner. Primary Care Providers (PCPs) or their designees must be available to members 24 hours a day, seven days a week.
All providers who oversee the member’s health care are responsible for providing the following appointments to Molina Healthcare of California (MHC) members in the timeframes noted:
- PCP Appointments
PCP Appointment Types
Standard
Emergency Care
Immediately
Urgent Care without prior authorization
Within ≤ 48 hours of the request.
Urgent Care with prior authorization
Within ≤ 96 hours of the request.
PCP Routine or Non-Urgent Care Appointments
Within ≤ 10 business days of the request.
PCP Adult Preventive Care
Within ≤ 20 business days of the request.
- Specialist Appointment Types
Specialist Appointment Types
Standard
Emergency Care Immediately Specialist Urgent Care without prior authorization “Within ≤ 48 hours of the request. Specialist Urgent Care with prior authorization
Within ≤ 96 hours of the request.
Specialist Routine or Non-Urgent Care Within ≤ 15 business days of the request.
- Behavioral Health Appointment
Behavioral Health Appointment Types
Standard
Urgent Care with a Behavioral Health Provider without prior authorization
Within ≤ 48 hours of the request.
Urgent Care requiring prior authorization with a Behavioral Health Provider
Within ≤ 96 hours of the request.
Routine or Non-Urgent Care Appointments with a Behavioral Health Provider
Within ≤ 10 working days of the request.
Behavioral Health Non-life-threatening emergency
Within ≤ 6 hours of the request.
BH – Routine Follow-up with Prescribers (i.e., Psychiatrist)
Within ≤ 30 business days from the initial appointment for a specific condition
BH – Routine Follow-up with Non-Prescribers
Within ≤ 10 business days from the initial appointment with non-prescribers (i.e., non-physician mental health care or substance use disorder provider) for a specific condition
Routine or Non-Urgent Care Appointment with a Non-Physician Mental Health Provider or substance use disorder providers
Within ≤ 10 working days of the request.
- Ancillary Access
Ancillary Access Type
Ancillary Access Standards
Non-urgent appointment for ancillary services.
Within ≤ 15 business days.
- Initial Health Assessment and Maternity Appointments
Initial Health Assessment and Maternity Appointments
Standards
Initial Health Assessment (IHA) for a New Member (under 18 months of age) Within 120 days of the enrollment or within periodicity timelines established by the American Academy of Pediatrics (AAP) for ages 2 and younger, whichever is less. Initial Health Assessment (IHA) for a New Member (over 18 months of age through 20 years of age) Within 120 days of the enrollment. The IHA must follow the most recent AAP periodicity schedule appropriate for the child’s age, and the scheduled assessments and services must include all content required by the Early, Periodic, Screening, Diagnosis and Treatment (EPSDT) program for the lower age nearest to the current age of the child. Initial Health Assessment (IHA) for a New Member (age 21 years and older)
Within 120 days of the enrollment.
Maternity Care Appointments for First Prenatal Care Within ≤ 2 weeks of the request.
- After-hour Availability
After-hour Availability
After-hour Access Standards
After Hours Care 24 hours/day; 7 days/week availability After-Hour Instruction for Life-Threatening Emergency (when office is closed) “If this is a life-threatening emergency, hang up and dial 911.” Timely physician response to after-hour phone calls/pages.
Within ≤ 30 minutes.
Physician Response Time to After-Hour Phone Message, Calls and/or Pages Within 30 minutes of call, message and/or page. A clear instruction on how to contact the physician or the designee (on-call physician) must be provided for members.
- Provider Office
Provider Office
Standards
Office Telephone Answer Time (during office hours) Within ≤ 30 seconds of call. Office Response Time for Returning Member Calls (during office hours) Within same working day of call. Office Wait Time to be Seen by Physician (for a scheduled appointment)
Should not exceed 30 minutes from the appointment time.
Timely access standards are based on regulatory and accreditation standards. MHC monitors compliance with these standards and will implement corrective actions for access to healthcare services that do not meet the performance standards.
If you are unable to obtain a timely referral to an appropriate provider, please contact the DMHC Provider Complaint line toll-free at (877) 525-1295 or through their website.
For further instructions, please refer to the Access to Care section under:
For additional information on appointment access standards, contact your local Molina Quality functional area at (888) 562-5442.