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member news
GETTING AN
APPOINTMENT
How long
should you
have to wait?
We know it is important for
you to get care when you need
it. But it is not always possible for
a doctor to see you right away. You
may have to wait longer for some types
of appointments than others. For example, you
should be able to get an urgent care (care when you are sick) appointment
sooner than an appointment for a regular checkup.
We work with the doctors and clinics in our network to make sure you
can get care when you need it. We have always done this because we know
it is important.
Health plans in California have to meet certain standards for access to
care. The regulations to put this law into place are called the Timely Access
to Non-Emergency Health Care Services standards. There are different
standards for different types of appointments.
In the chart below are the standards for different types of
appointments. The waiting times for an appointment may be longer if
the provider feels that it will not harm your health if you have a longer
wait.
If you feel you are not getting care when you need it, call Member
Services at
1-800-700-3874
.
Type of care you need Time to get an appointment
Urgent care
Within 48 hours of when you call
Non-urgent primary care
Within 10 business days of when you call
Non-urgent specialty care
Within 15 business days of when you call
Non-physician, non-urgent
mental health care
Within 10 business days of when you call
Non-urgent diagnostic services Within 15 business days of when you call
Do you know when you need a
referral from your Primary Care
Provider (PCP) before getting a
service? What is the difference
between a referral and an
authorization? Are you able to go to
a non-contracted provider? What
about an out-of-area doctor?
The rules of your health plan can
be confusing. But if you don’t follow
them, your services may not be
covered. Here is information to help
you follow the rules of your plan.
Referrals.
If you are assigned to
an Alliance PCP, you must have a
referral to see another doctor. There
are some exceptions to this. Please
see the box at right for a list of some
exceptions.
If your PCP thinks you need to
see another doctor, he or she will
fill out a Referral Consultation
Form. Your PCP sends a copy to
the doctor you are being referred
to and a copy to the Alliance. The
referral is how the other doctor and
the Alliance know your PCP has
approved the visit. If we don’t have
a referral, we will not pay the claim
from the other doctor.
Authorized referrals.
In most
cases, your PCP will refer you to
a doctor in our service area. Our
service area includes Santa Cruz,
Monterey and Merced counties. If
your PCP refers you to a doctor out
of our service area, he or she will
need to get approval (also called
authorization) from us in advance.
Confused by referrals
and authorizations?
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living
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