Guarenteed Access Program

Guaranteed Access Program

California law requires health plans to provide timely access to care. This means that there are limits on how long you have to wait to get health care appointments and telephone advice.

Our Timely Access Standards Include the Following:

NON URGENT

Primary Care Physician Wait Times:

Within 10 business days or within two weeks

Specialty Care wait Times:

Within 15 business days or within three weeks

Mental Health Appointment:

Within 10 business days or within two weeks

Examples of these non-physician mental health providers include counseling professionals, substance abuse professionals and qualified autism service providers.

Ancillary Appointments:

Within 15 business days or within three weeks

Examples of these non-urgent appointments for ancillary services include lab work or diagnostic testing, such as mammogram or MRI, and treatment of an illness or injury such as physical therapy.

URGENT

Primary Care Physician and Specialty Wait Times:

If prior authorization is not required by your health plan, you must be seen within 2 days

If prior authorization is required by your health plan, you must be seen within 4 days

Telephone Wait Times

You can call 24 hours a day, 7 days a week to talk to a qualified health professional to decide if your health problem is urgent. If someone needs to call you back, they must call you within 30 minutes. Look for the phone number on your health plan membership card.

If you call your plan’s customer service phone number, someone should answer the phone within 10 minutes during normal business hours.

Exceptions:

The purpose of the timely access law is to make sure you get the care you need. Sometimes you need appointments even sooner than the law requires. In this case, your doctor can request that the appointment be sooner.

Sometimes waiting longer for care is not a problem. Your provider may give you a longer wait time if it would not be harmful to your health. It must be noted in your record that a longer wait time will not be harmful to your health.

If you cannot get a timely appointment in your area because there are not enough providers, your health plan must help you get an appointment with an appropriate provider.