Medical Records Documentation, Management & Delegation Oversight
WHA is required by our accreditation and licensing agencies to review medical record-keeping systems of its contracted providers.
Contact WHA's Member Services department and ask to speak with WHA's Corporate Quality Director or the Quality Improvement department with any questions regarding medical record requirements.
Access & Availability
The effective date of the Timely Access Regulations is 1/17/11.
The Timely Access Regulations establish appointment availability standards for primary care physicians, specialist physicians, ancillary providers (physical therapy, radiology, laboratory, etc.), and mental health providers.
No. The Timely Access Regulations do not apply to:
- Preventive care (including routine physicals and well-child care);
- Periodic follow-up care, including but not limited to, standing referrals to specialists for chronic conditions, periodic office visits for pregnancy, cardiac care, and mental health care;
- Laboratory and radiological monitoring for recurrence of disease.
All of these types of care are not subject to the Timely Access Regulations and may be scheduled consistent with professionally recognized standards of practice.
The applicable waiting time for a particular appointment may be extended only if the referring or treating licensed health care provider, acting within the scope of his or her practice and consistent with professionally recognized standards of practice, has determined and noted in the relevant record that a longer waiting time will not have a detrimental impact on the health of the patient.
No. This determination may be made only by the referring or treating licensed health care provider, acting within the scope of his or her practice and consistent with professionally recognized standards of practice.
No. The Timely Access Regulations do not set forth specific chart documentation standards, other than to say that this decision must be documented in the relevant record.
"Advanced access" means offering an appointment to a patient with a primary care physician (or nurse practitioner or physician's assistant) within the same or next business day from the time an appointment is requested (or a later date if the patient prefers not to accept the appointment offered within the same or next business day). If a primary care physician offers "advanced access," it is considered to comply with the appointment availability standards in the Timely Access Regulations.
Health plans are required to measure and monitor the performance of their provider networks against the appointment availability standards. As part of this measurement and monitoring process, health plans will focus on overall performance trends and patterns at the IPA/medical group level.
For patients calling after-hours with urgent, non-emergency, situations that cannot wait until the next business day should receive one of the following options:
- When speaking to a live person:
- Stay on the line and be connected to the doctor on call.
- Leave a name and number and a physician or qualified healthcare professional will call you back within 30 minutes.
- Reach the doctor at another number, which is given.
- Appropriate Emergency Instructions:
- If a patient calling after-hours states he/she is dealing with an emergency the patient must be told to call 911 or referred to the nearest emergency room.
WHA contracts with Optum,® an accredited organization to provide nurse advice line services to all WHA members 24 hours a day, seven days a week, 365 days a year. Optum also has bi-lingual nurses that can assist your patients whose preferred spoken language is Spanish.
WHA's dedicated phone line for the Nurse Advice Line is 877.793.3655.
Advantage Referrals
WHA's Advantage Referral Program (ARP) allows our members more options when specialty care is needed. Under this unique program members may seek care and services from specialists associated with medical groups other than their own. To qualify, the ARP specialist must be in WHA's network and accept Advantage Referrals. Prior authorization is not required, but a referral from the member's PCP is needed to establish medical necessity and identify the type of specialist that is needed.
Can I use Advantage Referral?
Members who are assigned to a PCP from one of the following medical groups are eligible for the Advantage Referral program:
- Dignity Health | Mercy Medical Group
- Dignity Health | Woodland Clinic Medical Group
- Hill Physicians Medical Group - Sacramento
- Providence Medical Network (formerly, St. Joseph Health Medical Network)
- Meritage Medical Network
- NorthBay Healthcare
UC Davis-affiliated enrollees are not eligible to participate in the Advantage Referral Program.
Not all WHA contracted specialists accept Advantage Referrals. Participation in referral programs, if applicable, is listed in the physician listing in WHA's Provider Directory. The Provider Directory is available online or you may call a Member Services representative for assistance, Monday to Friday between 8 a.m. and 5 p.m. at: 916.563.2250.
Advantage Referral (AR) specialists may provide consultations and order routine lab work and plain film x-rays when needed. If additional testing, procedures, surgeries, or other non-routine services are needed, the AR specialist must notify the member's assigned PCP and obtain prior-authorization to ensure further coverage. The program does not include rehab, PT, ST or OT services from non-group WHA providers.
Send claims for AR services to the Claims Dept. of the member's assigned medical group or IPA, and mark them as "Advantage Referral" for faster processing.
Provider Termination
WHA encourages practitioners to give their Medical Group/IPA as much prior notice as possible when leaving a Group. WHA is required by regulatory and accrediting agencies to notify members that are affected by the termination of a practitioner or practice group in general, family and internal medicine or pediatrics, at least 30 calendar days before the effective termination date.