Access and Availability

The Department of Managed Health Care (DMHC) Timely Access to Non-Emergency Health Care Services regulation require Health Plans/Preferred IPA to asses and report appointment availability.  Health Plan or Preferred IPA will conduct phone calls to provider offices via contracted vendor to conduct annual Timeliness Access survey.  Please ensure all provider office staff and third party answering services are educated on the requirements. Provider offices will automatically be flagged non-compliant if they refuse to participate in the survey. Corrective Action Plan (CAP) will be issued if a provider office is non-compliant on the Access Availability survey.

 Appointment Access

  • Access to Non-Urgent Appointment for Primary Routine care with Primary Care Physician (PCP)
  • Within 10 business days of request
  • Access to Urgent Care Appointments that do not require prior Authorization (PCP or Specialist)
  • Within 48 hours of request
  • Access to Non-Urgent Appointment for Primary Routine care with a Specialist
  • Within 15 business days of request

Wait Times from Date of Request for Appointment

After-Hour Access Compliance Requirements

  • Include “If this is a medical emergency, please hang up and dial 911 or go to the nearest Emergency Room.”
  • Include “You may expect a call back within 30 minutes” on the answering machine message.
  • Educate your answering service to inform the member he or she can expect a call back within 30 minutes.
  • Validate that on-call providers through the exchange are receiving and responding to calls and/or messages.
  • Conduct an audit of Exchange services to ensure that required components are addressed.

Provider Office Waiting Time

  • Patient’s wait time should be less than 30 minutes from the time of the scheduled appointment.

Patient No-show

  • If a member does not keep a scheduled appointment (a no-show) it should be documented in his or her medical record.