Timely access to care
Blue Shield of California Promise Health Plan wants to make sure you receive timely access to medical care and services. This document includes standards that are required by law, and can help you understand what to expect when you schedule medical appointments or use other health care services. If you need help making an appointment, please call us at the Customer Care number on the back of your Blue Shield of California member ID card.
| URGENT CARE | ACCESS TO CARE |
|---|---|
| For services that don’t need prior approval | Within 48 hours |
| For services that do need prior approval | Within 96 hours |
| NON-URGENT CARE | ACCESS TO CARE |
|---|---|
| Primary care appointment | Within 10 business days |
| Specialist appointment | Within 15 business days |
| Preventive care appointment | Within 30 business days |
| Ancillary care provider appointment | Within 15 business days for services where prior authorization has been obtained |
| SPECIALTY CARE | ACCESS TO CARE |
|---|---|
| Urgent specialist exam (no authorization required) | Within 48 hours of request, if no authorization is required. When a Practitioner refers a member for an urgent care need to a specialist (i.e., fracture) and authorization is not required, the member must be seen within 48 hours or sooner as appropriate from the time the member was referred |
| Urgent specialist exam (with authorization required) | Within 96 hours of request, if authorization is required. When a Practitioner (e.g., a referral to a specialist by a PCP or another specialist) refers a member for an urgent care need to a specialist (i.e., fracture) and an authorization is required, the member must be seen within 96 hours or sooner as appropriate from the time the referral was first authorized |
| Routine specialist visit, non-urgent exam | Within 15 business days |
| VISION CARE | ACCESS TO CARE |
|---|---|
| Urgent vision services | Within 48 hours of request when it is consistent with the patient’s individual needs and as required by professionally recognized standards of vision practice |
| Non-urgent vision services | Within 15 business days of the request for an appointment |
| Preventive care vision services | Within 15 business days of the request for an appointment |
| BEHAVIORAL HEALTH | ACCESS TO CARE |
|---|---|
| Emergency care | Call 911 |
| Non-life-threatening emergency | Within 6 hours |
| Urgent care | Within 48 hours |
| Routine office visit for non-urgent appointment with a psychiatrist | Within 15 business days |
| Non-urgent appointment with a non-physician mental health care provider | Within 10 business days |
| Follow-up routine care appointment with prescriber | Within 15 business days |
| Follow-up routine care appointment with non-prescriber | Within 10 business days |
| TELEPHONE INQUIRIES | ACCESS TO SERVICE |
|---|---|
| Access to a health professional for telephone screenings | 24 hours/day, 7 days/week |
Accessibility:
PCP: Family Medicine (General Practice & Family Practice), Internal Medicine, Pediatrics, and OB/GYNs practicing as a PCP (Medi-Cal only).
One PCP of each primary type within 10 miles or 30 minutes (or an approved/pending Alternate Access Standard) from each member’s residence or workplace in the approved service area as appropriate by age.
OB/GYN: One OB/GYN (practicing as a PCP or specialist) within 15 miles or 30 minutes from each member's residence or workplace in the approved service area.
Time standards for appointments:
The time standards for appointments may be extended when the referring, treating, or health professional providing triage services determines that a longer wait time will not have a detrimental effect on the health of the patient.
Subcontractor and Downstream Subcontractor Network Certification:
The report is the Subcontractor and Downstream Subcontractor Network Certification submitted to Department of Health Care Services.
Interpreter services:
For availability of interpreter services at the time of your appointment, consult the provider directories available at blueshieldca.com or call the Customer Care number on the back of your Blue Shield member ID card.
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Last updated: 12/28/2023