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
PCP Urgent Care without prior authorization
48 hours
PCP Urgent Care with prior authorization
96 hours PCP Routine or Non-Urgent Care Appointments
10 business days
PCP Adult Preventive Care
20 business days
- Specialist Appointment Types
Specialist Appointment Types
Standard
Specialist Urgent Care without prior authorization 48 hours Specialist Urgent Care with prior authorization
96 hours
Specialist Routine or Non-Urgent Care 15 business days
- Behavioral Health Appointment
Behavioral Health Appointment Types
Standard
Urgent Care with a Behavioral Health Provider without prior authorization
48 hours
Urgent Care requiring prior authorization with a Behavioral Health Provider
96 hours
Routine or Non-Urgent Care Appointments with a Specialty Care Physician (i.e., psychiatrist)
15 business days
Routine or Non-Urgent Care Appointments with a Behavioral Health Provider
10 business days of the request
Behavioral Health Non-life-threatening emergency
6 hours of the request
Behavioral Health – Routine Follow Up with Prescribers (i.e., Psychiatrist)
30 business days from the initial appointment for a specific condition
Behavioral Health – Routine Follow-up with Non-Physician Mental Health Providers
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 BH Provider or Substance Use Disorder Providers 10 business days of the request - Ancillary Access
Ancillary Access Type
Ancillary Access Standards
Routine or Non-Urgent Care Appointment for Ancillary Services
15 business days of the request
- Initial Health Assessment and Maternity Appointments
Initial Health Assessment and Maternity Appointments
Standards
Initial Health Appointment (IHA) for a New Member For Members under the age of 18 months, IHA must be performed within 120 calendar days following the date of enrollment or within periodicity timelines established by the American Academy of Pediatrics (AAP) for ages two (2) and younger, whichever is less.
For Members over 18 months of age through 20 years of age, within 120 days of enrollment. The IHA must follow 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, Diagnostic and Treatment (EPSDT) program for the lower age nearest to the current age of the child.
For Members 21 years and older, within 120 days of enrollment. The IHA must include preventive services for adults recommended in the most current edition of the Guide to Clinical Preventive Services, U.S. Preventive Services Task Force, (USPSTF), specifically all USPSTF “A” and “B” recommendations, for provided preventive screening, testing, and counseling services.Prenatal First Appointment 2 weeks
- After-hour Availability
After-hour Availability
After-hour Access Standards
After Hours Care 24 hours/day; 7 days/week availability After-Hour Instruction for Emergency Life-threatening emergency instruction should state: “If this is a life-threatening emergency, hang up and dial 911.” 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) Return calls within same business 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.