Estándares de acceso y disponibilidad

Gold Coast Health Plan (GCHP) is responsible for maintaining an adequate provider network, ensuring that members have access to care and receive timely care as appropriate for their condition, 24 hours a day, seven days a week. Safeguarding member access to care helps members stay healthy and avoid additional costly care.

The access and availability standards found on this page are set forth by the state Department of Health Care Services (DHCS) for all Medi-Cal providers. Medi-Cal health plans are mandated to conduct yearly provider surveys to a sampling of our contracted providers. This helps identify the level of member access and availability and determine whether our network meets the timely access standards. It is crucial that GCHP members can access medical help during normal working hours, as well as after hours.

Below is a list of some of the detailed standards that DHCS requires GCHP providers to meet.

Proveedores de Atención Primaria (PCP)

Routine Appointments: Routine, non-emergent appointments should be available within 10 business days of the member’s request for an appointment. This requirement is for both new and established patients. Follow-up care for established patients should be accommodated as medically appropriate.

Physical Examination Appointments: These appointments should be made available within six weeks of a member’s request. When possible, special consideration should be given to members who require physical examinations as part of their employment.

Specialty Care Providers (SPC)

Timeframes for access to routine specialty care should be dependent upon diagnosis and the urgency of the condition. However, appointments should be available within 15 business days of a member’s request for an appointment.

First Prenatal Appointment

The first prenatal visit must be scheduled within two weeks of a member’s request.

Urgent Care Appointments

Medically indicated urgent appointments should be made the same day or within 48 hours of the member’s call for an appointment. The request for services should be evaluated and the urgency assessed to determine what the medical problem is and the need for urgent treatment. Depending on the nature of the medical problem, the member should be triaged to the most appropriate care site.

After-Hours Calls

When members call provider offices after hours, they should be advised by a recorded outgoing message that if the situation is a true medical emergency, the member should hang up and dial 911 or go to the nearest hospital. This advice should be recorded in, at least, English and Spanish and possibly other languages if the provider has a large amount of members that they care for routinely who speak another language.

Access and Availability Surveys

Providers are responsible for ensuring backup coverage during their absence, including while the provider is handling an emergency call at a hospital. After-hours surveys are designed to help determine provider access and availability for urgent after-hours care by testing a provider's after-hours messaging content and instruction via answering service or through voicemail / messaging equipment and software.

Here is an overview:

To pass the survey, all questions listed in the After-Hours Access table need to be answered with a “Y.”
Those provider offices that receive at least one “N” will receive a “failed” score and are required to adjust their messaging process and messaging content to be fully compliant.
Notification letters are sent out informing the provider office of any questions / areas that have failed in the survey.
Provider offices that are identified with failed scores will be placed on a Corrective Action Plan (CAP) and resurveyed to verify that their after-hours messaging meets the Medi-Cal compliance metrics.

Is the practitioner’s answering system for after-hours urgent care / emergency physician coverage available 24 hours, seven days a week?
Is there an option to speak to a live party or phone number to reach a live person?
Does the recorded message include instructions for a member to hang up and dial 911 or go to the nearest Emergency Room if they are having an emergency?
Is the recorded emergency message available in Spanish?
If there is a live answering service, do they direct the member to dial 911 or go to the nearest Emergency Room, connect the caller to a provider or nurse to triage, or take caller’s information and give to doctor or on-call doctor?

Appointment Access Standards for Medi-Cal

Appointment access Standards for Medi-Cal

Below is a brief description of the access standards for GCHP Medi-Cal members:

Tipo de atención	Wait Time
Emergency Services	Immediately.
Atención de Urgencias	Within 48 hours (no prior authorization required). Within 96 hours (if prior authorization is required).
Non-Urgent Primary Care Appointment	Within 10 business days of request for appointment.
Non-Urgent Behavioral Health Appointment	Within 10 business days of request for appointment.
Non-Urgent Specialty Care Appointment	Within 15 business days of request for appointment.
Phone Wait Time	Within three to five minutes, whenever possible.
Ancillary Services for Diagnosis or Treatment	Within 15 business days of request for appointment.
Long Term Care (LTD)	Within seven business days of request.
Centro de enfermería especializada (SNF)	Within seven business days of request.
Immediate Care Facility / Developmentally Disabled (ICF-DD)	Within seven business days of request.
Community Based Adult Services (CBAS)	Capacity cannot decrease in aggregate statewide below April 2012 level.
Initial Health Appointment (IHA)	Within 120 calendar days from enrollment.
Waiting Time in Office	Not to exceed 45 minutes after time of appointment.
Patient Call Back	Within 60 minutes.
Sensitive Services	Ensure confidentiality and ready access to sensitive services in a timely manner and without barriers – NO AUTHORIZATION REQUIRED.

If you have any questions or concerns, or are experiencing challenges meeting any of these requirements, email GCHP’s Provider Relations Team at ProviderRelations@goldchp.org.