Access to Care
Molina maintains access to care standards and processes for ongoing monitoring of access to health care (including behavioral health care) provided by contracted primary PCPs (adult and pediatric) and participating specialist (to include OB/Gyn, behavioral health Providers, and high volume and high impact specialists). Providers are required to conform to the Access to Care appointment standards listed below to ensure that health care services are provided in a timely manner. The standards are based on 90% or greater availability for Emergency Services and 90% or greater for all other services. The PCP or his/her designee must be available 24 hours a day, 7 days a week to Members.
Appointment Access
All Providers who oversee the Member’s health care are responsible for providing the following appointments to Molina Members in the timeframes noted:
Medical Appointment Types |
Appointment Scheduling Timeframes |
| PCP (Well Care Visit) | Not to exceed thirty (30) calendar days |
| PCP (Routine Sick Visit) | Not to exceed seven (7) calendar days with an urgent care schedule (see below); otherwise, not to exceed twenty-four (24) hours |
| PCP (Urgent Care Visit) | Not to exceed twenty-four (24) hours |
| Specialists | Not to exceed forty-five (45) calendar days |
| Dental Providers (Routine Visits) | Not to exceed forty-five (45) calendar days |
| Dental Providers (Urgent Care) | Not to exceed forty-eight (48) hours |
Behavioral Health Appointment Types |
Appointment Scheduling Timeframes |
|
Behavioral Health/Substance Use Disorder Providers (routine visit) |
Not to exceed fourteen (14) calendar days |
|
Behavioral Health/Substance Use Disorder Providers (urgent visit) |
Not to exceed fourteen (14) calendar days |
|
Behavioral Health/Substance Use Disorder Providers (post- discharge from an acute psychiatric hospital when the Contractor is aware of the Member’s discharge) |
Not to exceed seven (7) calendar days |
| Urgent Care Providers | Not to exceed twenty-four (24) hours |
| Emergency Providers |
Immediately (twenty-four (24) hours a day, seven (7) days week) and without Prior Authorization |
Additional information on appointment access standards is available from your local Molina Quality Department toll free at (844) 826-4335.
Office Wait Time
For scheduled appointments, the wait time in offices should not exceed forty-five (45) minutes. All PCPs are required to monitor waiting times and adhere to this standard.
After Hours
All Providers must have back-up (on call) coverage after hours or during the Provider’s absence or unavailability. Molina requires Providers to maintain a twenty-four (24) hour phone service, seven (7) days a week. This access may be through an answering service or a recorded message after office hours. For PCPs and OB/GYNs, if a recorded message is used, it must provide an option to direct the Member to a live person. The service or recorded message should instruct Members with an Emergency to hang-up and call 911 or go immediately to the nearest emergency room.
Please visit the Provider Manual for additional information on access and availability.