Timely Access to Care

Health plans in California must meet timelines for providing care and services to members seeking treatment.  The Timely Access Regulations set specific standards for patients to obtain a medical appointment in certain situations.  The standards are shown in the chart below.

Exceptions to the Appointment Availability Standards

Preventive Care Services and Periodic Follow Up Care: Preventive care services and periodic follow up care are not subject to the appointment availability standards.  These services may be scheduled in advance consistent with professionally recognized standards of practice as determined by the treating licensed health care provider acting within the scope of his or her practice.  Periodic follow-up care includes but is not limited to, standing referrals to specialists for chronic conditions, periodic office visits to monitor and treat pregnancy, cardiac or mental health conditions, and laboratory and radiological monitoring for recurrence of disease.

Extending Appointment Waiting Time: The applicable waiting time for a particular appointment may be extended if the referring or treating licensed health care provider, or the health professional providing triage or screening services, as applicable, 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.

Rescheduling Appointments: When it is necessary for a provider or member to reschedule an appointment, the appointment shall be promptly rescheduled in a manner that is appropriate for the member's health care needs and ensures continuity of care consistent with good professional practice. 

Advanced Access: The primary care appointment availability standard in the chart may be met if the primary care physician (PCP) office provides "advanced access.”  "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 You Need Help Obtaining Timely Care

If you need help obtaining timely care:

  • First, contact your PCP or the referring provider for assistance.  They may secure an appointment or find another provider that can see you sooner.  Your provider may also decide that a longer waiting time will not be detrimental to your health.
  • If your provider is not able to assist, contact WHA’s Member Services.

Services that Do Not Require A Referral

WHA wants to make it easier for you to receive the right care, at the right time, and in the right place—with the best services available.  The following services, when obtained from a participating provider, do not require a referral from your PCP:

  • On-call Physician Services: The on-call physician for your PCP can provide care in place of your physician.
  • Behavioral/Mental Health Services: See the back of your WHA ID card for the telephone number for your mental health benefits provider or visit mywha.org/bh.
  • Gynecology Examination/Obstetrical Services
  • Vision: An annual eye exam (when covered)
  • Emergency Care: If you are in an emergency situation, call 911 or go to the nearest hospital emergency room.  Notify your PCP the next business day or as soon as possible.
  • Urgent Care: When an urgent care situation arises while you are in WHA’s Service Area, call your PCP at any time of the day, including evenings and weekends.

WHA also offers all members access to California-licensed, registered nurses through Nurse24. Screening, triage, and health education services are available 24 hours a day, 7 days a week. Use Nurse24 to help answer questions about a medical problem you may have, including:

  • Caring for minor injuries and illnesses at home
  • Seeking the most appropriate help based on the medical concern, including help for behavioral health concerns
  • Identifying and addressing emergency medical concerns

Interpreter services are also available upon request.  Call 877.793.3655 or visit mywha.org/healthsupport to chat with a nurse or to send a secure email.

Cultural and Linguistic Services

WHA and our providers support your right to obtain accessible health care.  If you have needs with regard to your culture, language, or a disability, please contact your physician’s office first or call WHA’s Member Services.

If you need assistance in a language other than English, your doctor’s office and WHA offers interpretation services in many languages, including Spanish and American Sign Language, at no additional cost to you—let your physician’s office know when you call for an appointment. View the Notice of Language Assistance for more information and assistance from Member Services.  The deaf and hard of hearing may use WHA’s TDD/TTY line at 888.877.5378.

Additional information about access to care and how to obtain a referral or prior authorization is available at mywha.org/planbasics and your EOC.

URGENT CARE

Prior authorization NOT required by health plan

48 hours

 

Prior authorization REQUIRED by health plan

96 hours

NON-URGENT CARE

Primary Care Physician

10 business days

 

Specialty Care Physician

15 business days

Non-Physician Mental Health provider[1]

10 business days

 

Ancillary Services[2]

15 business days

Telephone triage and screening services with a health professional:

  • Waiting time cannot exceed 30 minutes

WHA members can reach the Nurse24 nurse advice line 24 hours per day, 7 days per week, 365 days per year by calling 877.793.3655 toll-free or 800.877.8793 TTY.

Speaking with a WHA member service representative by phone during normal business hours:

  • Waiting time cannot exceed 10 minutes

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

[2] Examples of non-urgent appointment 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.

         
         
         
         
         
         
         

 

Last review date: January 22, 2020

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