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    OpenPayerPolicy UpdatesAdministrative/Operational PolicyCenCal Health Timely Access Policy Update | OpenPa…
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    CurrentCenCal HealthPolicy PS-CR04

    Timely Access to Care Requirements and Ongoing Monitoring

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    Establishes appointment, telephone access, triage, and facility-placement timeliness requirements for CenCal Health Members, with ongoing monitoring, audits, reporting, and corrective actions for CenCal Health and participating providers serving Medi-Cal Members.

    Policy Summary
    PayerCenCal Health
    PolicyTimely Access to Care Requirements and Ongoing Monitoring
    Policy CodePolicy PS-CR04
    Change TypeAdministrative updateno material clinical or coverage changes
    Effective DateJan 1, 2024
    Next Review DateN/A
    Key ActionProviders must offer Covered Services appointments within the applicable urgent, routine, specialty, mental health, ancillary, and facility-placement timeframes.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    48 hoursUrgent appointment without prior authorization
    96 hoursUrgent appointment requiring prior authorization
    10 daysRoutine primary care and mental health appointment limit
    15 daysRoutine specialty and ancillary care appointment limit
    24/7Telephone advice and physician support
    70%Timely access compliance benchmark

    Timely Access Requirements and Oversight

    Timely access and appointment requirements

    Members must be offered Covered Services within timeframes appropriate to their condition and no later than applicable California timeliness standards, unless the Member requests a later appointment.

    ALL of the following

    • Applicable access requirements

      • Appointment and facility-placement standards

        • Offer urgent care appointments without prior authorization within 48 hours and urgent care appointments requiring prior authorization within 96 hours.
        • Offer routine primary care and routine non-physician mental health care appointments within 10 business days.
        • Offer routine specialty care and routine ancillary care for diagnosis or treatment of injury or illness within 15 business days.
        • Make Long-Term Care, Skilled Nursing Facility, or Intermediate Care Facility availability available within 14 days of request.
        • Maintain Community Based Adult Services capacity so it does not decrease in aggregate statewide below the April 2012 level.
      • Provide Network Provider hours of operation to Members that are no less than the hours offered to non-Medi-Cal patients, or to Medi-Cal Fee-for-Service beneficiaries when the provider serves only Medi-Cal beneficiaries.
      • Maintain protocols for triaging Member calls, providing telephone medical advice, and accessing telephone interpreters 24 hours a day, seven days a week; during normal business hours, the wait to speak with a Member Services Representative must not exceed 10 minutes.
      • If an appointment waiting time is extended, document in the Member's medical record that waiting will not have a detrimental impact on the Member's health, document the provider's decision and make it available to DHCS upon request, and notify the Member of the decision and grievance rights.
      • Promptly reschedule appointments when necessary in a manner appropriate to the enrollee's health care needs and that ensures continuity of care.

    Monitoring and corrective action

    CenCal Health and participating providers are subject to ongoing monitoring, reporting, and corrective action to identify and resolve access deficiencies.

    ALL of the following

    • Participate in CenCal Health's Quality Improvement and Health Equity Transformation Program monitoring, review, evaluation, and access-improvement activities.
    • Support audits, surveys, complaint investigations, and analysis of appointment, missed-appointment, grievance, telephone-access, and provider-compliance data.
    • Use monitoring results to identify access barriers, report findings through the applicable quality committee structure and, when required, to the Department of Health Care Services.
    • Implement corrective action when access standards or equitable operating-hour requirements are not met, including responding in writing to a corrective action plan that identifies deficiencies, required standards, planned actions, and implementation timelines.
    • Demonstrate compliance through ongoing monitoring, monthly resurvey when applicable, and continued corrective-action-plan oversight until evidence of compliance is established.
    • Accept further interventions when necessary, which may include on-site education, assistance with practice efficiency or recruitment, and a freeze on Member assignment if the provider cannot attain compliance.

    Access Timeframes and Operational Benchmarks

    Appointment access standard
    ServiceUrgent care appointment without prior authorization
    TimeframeWithin 48 hours
    RequirementCovered Services appointments must be offered within the applicable timeframe
    Appointment access standard
    ServiceUrgent care appointment requiring prior authorization
    TimeframeWithin 96 hours
    RequirementCovered Services appointments must be offered within the applicable timeframe
    Appointment access standard
    ServiceRoutine primary care appointment
    TimeframeWithin 10 business days
    Appointment typeRoutine care
    Appointment access standard
    ServiceRoutine specialty care appointment
    TimeframeWithin 15 business days
    Appointment typeSpecialty care
    Appointment access standard
    ServiceRoutine non-physician mental health care appointment
    TimeframeWithin 10 business days
    Appointment typeRoutine mental health care provided by a non-physician
    Appointment access standard
    ServiceRoutine ancillary care for diagnosis or treatment of injury or illness
    TimeframeWithin 15 business days
    Appointment typeAncillary care
    Facility availability standard
    FacilitiesLong-Term Care, Skilled Nursing Facility, or Intermediate Care Facility providers
    Availability standardWithin 14 days of request
    Access requirementAvailability must be provided within the applicable facility-placement timeframe
    Capacity standard
    ServiceCommunity Based Adult Services centers
    Capacity standardCapacity cannot decrease in aggregate statewide below the April 2012 level
    MeasurementAggregate statewide capacity
    Telephone access standard
    ContactMember Services Representative
    Maximum waitNo more than 10 minutes
    Applicable hoursDuring normal business hours
    Authorization turnaround standard
    ProcessPrior authorization requests
    Standard turnaroundFive business days
    ExtensionMay be extended up to 14 days when additional information is needed
    Compliance benchmark
    MeasureTimely access compliance rate
    Internal benchmark70%
    Monitoring basisBenchmark is based on DHCS methodology
    Advanced Access standard
    Access optionPrimary care appointment with a primary care physician or other qualified primary care provider
    AvailabilityWithin the same or next business day from the time an appointment is requested
    Member preferenceAdvance scheduling at a later date is allowed if the enrollee prefers not to accept the offered appointment

    Provider and Delegated Entity Responsibilities

    Denial Risk

    Maintain Equitable Provider Hours

    Offer CenCal Health Members hours of operation that are no less than the hours offered to comparable non-Medi-Cal patients, or to Medi-Cal Fee-for-Service beneficiaries when the practice serves only Medi-Cal beneficiaries.

    Note

    Meet Appointment Access Standards

    Offer Covered Services within the applicable access timeframe, unless the Member requests a later appointment. Standards include urgent care, routine primary and specialty care, non-physician mental health care, ancillary care, LTC/SNF/ICF placement, and CBAS availability.

    • Urgent care without prior authorization: within 48 hours.
    • Urgent care requiring prior authorization: within 96 hours.
    • Routine primary care: within 10 business days; routine specialty care: within 15 business days.
    • Routine non-physician mental health care: within 10 business days; routine ancillary care for injury or illness diagnosis or treatment: within 15 business days.
    • LTC, SNF, or ICF availability: within 14 days of request. CBAS capacity may not decrease statewide below the April 2012 aggregate level.
    Documentation Required

    Document and Notify for Extended Wait Times

    Extend an applicable appointment waiting time only when the treating provider documents that waiting will not detrimentally affect the Member's health. Document the decision in the medical record, make it available to DHCS upon request, and notify the Member of the decision and the right to file a grievance disputing the extension.

    • Record the treating provider's determination that the delay will not have a detrimental impact on the Member's health.
    • Document the provider's decision in the medical record and provide it to DHCS upon request.
    • Notify the Member and explain the Member's right to file a grievance.
    Note

    Promptly Reschedule Appointments

    When a provider or enrollee must cancel or change an appointment, promptly reschedule it in a manner appropriate to the enrollee's healthcare needs, supports continuity of care, and is consistent with good professional practice and this policy.

    Unsupported block type: prior_auth

    Note

    Authorize Alternative Facility Placement

    When no SNF or LTC bed is available, Medical Management staff may authorize placement in an out-of-network facility to ensure timely access to the appropriate level of care.

    • Use alternative out-of-network placement when an appropriate SNF/LTC bed is unavailable.
    • Ensure the Member receives timely access to the appropriate level of care.
    Documentation Required

    Participate in Monitoring and Corrective Action

    Participate in CenCal Health's QIHETP monitoring, reporting, review, evaluation, audits, and corrective-action activities addressing access and availability of Covered Services. Providers and delegated entities must implement required corrective actions and provide written responses when deficiencies are identified.

    • Support monitoring of appointment availability, access standards, time and distance standards, timely access, and alternative access.
    • Respond to corrective action plans with the actions and timeline needed to address deficiencies.
    • Remain under monitoring and participate in resurvey or other follow-up until compliance is demonstrated.

    Policy Terms

    Definition
    ProviderIndividual provider or medical group
    Access definitionPrimary care appointment with a primary care physician or other qualified primary care provider within the same or next business day from the request
    Later schedulingAdvance scheduling at a later date is allowed if the enrollee declines the offered appointment
    Definition
    Service categoryAncillary services or supplies
    Included categoriesPharmaceutical, laboratory, optometry, prosthetic, and orthopedic supplies or services
    Additional categoriesDurable medical equipment suppliers and home-health service providers are included
    Definition
    Starting pointInitial request for health care services by an enrollee or the enrollee's treating provider
    EndpointEarliest date offered for the appointment
    Included timeTime for obtaining plan authorization and completing any other plan condition or requirement
    Definition
    Program typeOutpatient, facility-based program
    Clinical and support servicesSkilled nursing, social services, therapies, and personal care
    Additional servicesFamily or caregiver training and support, nutrition services, transportation, and other services
    Definition
    Legal sourcesWelfare and Institutions Code sections 14000 et seq. and 14131 et seq., and applicable California regulations
    Program sourcesMedi-Cal Provider Manual, California Medicaid State Plan, and California Section 1115 Medicaid Demonstration Project
    Contractual sourcesCenCal Health's contract with DHCS, applicable All Plan Letters, and other federally approved managed care authorities maintained by DHCS
    Definition
    AgreementHas a Network Provider Agreement with CenCal Health, its Subcontractor, or Downstream Subcontractor
    Funding relationshipReceives Medi-Cal funding directly or indirectly
    Permitted roleMay order, refer, or render Covered Services under the CenCal Health-DHCS contract
    Definition
    Care typeSpecialized rehabilitative services and care
    Qualifying facilitiesSkilled Nursing Facility, subacute facility, pediatric subacute facility, or Intermediate Care Facility
    AbbreviationLTC
    Definition
    Facility statusLicensed as a Skilled Nursing Facility by the California Department of Public Health, or a qualifying distinct part or unit of a hospital
    CertificationCertified and enrolled for participation as a Skilled Nursing Facility in the Medi-Cal Program
    StandardsMeets applicable California regulatory standards, including the standards specified in 22 CCR section 51215
    Definition
    Program purposeSystematic and continuous activities to monitor, evaluate, and improve health equity and health care delivered to Members
    Quality focusImproves health equity and health care
    Governing requirementsActivities follow applicable laws, regulations, and the DHCS Medi-Cal Managed Care Agreement
    Definition
    UsesHealth care delivery, diagnosis, consultation, treatment, transfer of medical data, and education
    TechnologyInteractive audio, video, or data communications
    Communication standardReal-time or near-real-time two-way transfer of medical data and information; telephone conversations and email do not constitute telemedicine under this policy
    Definition
    PurposeAssessment of an enrollee's health concerns and symptoms to determine the urgency of the need for care
    Qualified personnelPhysician, registered nurse, or other qualified health professional acting within the scope of practice
    Training requirementThe health professional must be trained to screen or triage an enrollee who may need care
    Definition
    MeasurementTime spent waiting by telephone
    ContactSpeaking with a physician, registered nurse, or other qualified health professional
    Professional qualificationThe health professional must be acting within the scope of practice and trained to screen or triage an enrollee who may need care
    Definition
    Care typeHealth care requiring prompt attention
    Seriousness thresholdDelay could pose an imminent and serious threat to the enrollee's health
    Examples of riskPotential loss of life, limb, or other major bodily function, or jeopardized ability to regain maximum function
    Policy Summary
    PayerCenCal Health
    PolicyTimely Access to Care Requirements and Ongoing Monitoring
    Policy CodePolicy PS-CR04
    Change TypeAdministrative updateno material clinical or coverage changes
    Effective DateJan 1, 2024
    Next Review DateN/A
    Key ActionProviders must offer Covered Services appointments within the applicable urgent, routine, specialty, mental health, ancillary, and facility-placement timeframes.
    SourceLink
    On This Page
    Timely Access Requirements and OversightAccess Timeframes and Operational BenchmarksProvider and Delegated Entity ResponsibilitiesPolicy Terms

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