California: Standards for Timely Access to Care

Covered health care services are provided and arranged in a timely manner appropriate for the nature of the covered person's condition consistent
with good professional practice. Provider networks, policies, procedures and quality assurance monitoring systems and processes are established
and maintained to ensure compliance with clinical appropriateness standards.

All network and provider processes necessary to obtain covered health care services, including but not limited to prior authorization processes,
are completed in a manner that assures covered health care services are provided to covered persons in a timely manner appropriate for the
covered person's condition.

When it is necessary for a provider or a covered person to reschedule an appointment, the appointment will be promptly rescheduled in a manner
that is: i) appropriate for the covered person's health care needs, ii) ensures continuity of care consistent with good professional practices and
iii) meets the California standards regarding the accessibility of provider services in a timely manner.

Interpreter services are coordinated with scheduled appointments for health care services in a manner that ensures interpreter services are provided at the time of the appointment, consistent with California standards without imposing an undue delay on the scheduling of the appointment.

Sufficient numbers of contracted providers will be maintained and contracted provider networks will have adequate capacity and availability of licensed health care providers to offer covered persons appointments that meet the following timeframes:
  • Urgent care appointments for services that do not require prior authorization: within 48 hours of the request for appointment.
  • Urgent care appointments for services that require prior authorization: within 96 hours of the request for appointment.
  • Non-urgent appointments for primary care: within ten business days of the request for appointment.
  • Non-urgent appointments with specialist physicians: within fifteen business days of the request for appointment.
  • Non-urgent appointments with a non-physician mental health care provider: within ten business days of the request for appointment.
  • Non-urgent appointments for ancillary services for the diagnosis or treatment of injury, illness, or other health condition: within fifteen business days of the request for appointment;

Time Frame Exceptions:
  • 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 covered person.
  • Preventive care services, and periodic follow up care, including but 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, 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.

Triage or screening services by telephone will be provided or arranged 24 hours per day, 7 days per week. "Triage" or "screening" means the assessment of a covered person's health concerns and symptoms via communication, with a physician, registered nurse, or other qualified health professional acting within his or her scope of practice and who is trained to screen or triage an insured who may need care, for the purpose of determining the urgency of the covered person's need for care. "Triage or screening waiting time" means the time waiting to speak by telephone with a physician, registered nurse, or other qualified health professional acting within his or her scope of practice and who is trained to screen or triage an insured who may need care.

Telephone triage or screening services are provided in a timely manner appropriate for the insured's condition. Triage or screening waiting time does not exceed 30 minutes. During normal business hours, the waiting time for a covered person to speak by telephone with an Assurant Health customer service representative knowledgeable and competent regarding the covered person's questions and concerns will not exceed ten minutes. A covered person will receive a scheduled call-back within 30 minutes.