Access to Care

Molina maintains access to care standards and processes for ongoing monitoring of access to health care (including behavioral health care) provided by contracted primary PCPs (adult and pediatric) and participating specialist (to include OB/Gyn, behavioral health Providers, and high volume and high impact specialists). Providers are required to conform to the Access to Care appointment standards listed below to ensure that health care services are provided in a timely manner. The standards are based on 90% or greater availability for Emergency Services and 90% or greater for all other services. The PCP or his/her designee must be available 24 hours a day, 7 days a week to Members.

Appointment Access

All Providers who oversee the Member’s health care are responsible for providing the following appointments to Molina Members in the timeframes noted:


Medical Appointment Types

Standard
 Routine, asymptomatic  Within 30 calendar days
 Routine, symptomatic  Within 7 calendar days
 Urgent Care  Within 24 hours
 After Hours Care  24 hours/day; 7 day/week availability
 Specialty Care (High Volume)  Within 45 calendar days
 Specialty Care (High Impact)  Within 45 calendar days
 Dental Providers (Routine Visits)  Not to exceed forty-five (45) calendar days 
 Dental Providers (Urgent Care)   Not to exceed forty-eight (48) hours 
 Urgent Specialty Care  Within 24 hours

Behavioral Health Appointment Types

Standard
 Life Threatening Emergency  Immediately
 Non-life-Threatening Emergency  Within 6 hours
 Urgent Care  Within 24 hours
 Routine Care  Within 21 calendar days
 Follow-up Routine Care (post- discharge from an acute psychiatric hospital when the Contractor is aware of the Member’s discharge)

 Within 7 calendar days
 Emergency Providers   Immediately (twenty-four (24) hours a day, seven (7) days week) and without Prior Authorization

 

Additional information on appointment access standards is available from your local Molina Quality Department toll free at (844) 826-4335.

Office Wait Time

For scheduled appointments, the wait time in offices should not exceed forty-five (45) minutes. All PCPs are required to monitor waiting times and adhere to this standard.

After Hours

All Providers must have back-up (on call) coverage after hours or during the Provider’s absence or unavailability. Molina requires Providers to maintain a twenty-four (24) hour phone service, seven (7) days a week. This access may be through an answering service or a recorded message after office hours. For PCPs and OB/GYNs, if a recorded message is used, it must provide an option to direct the Member to a live person. The service or recorded message should instruct Members with an Emergency to hang-up and call 911 or go immediately to the nearest emergency room.

Please visit the Provider Manual for additional information on access and availability.