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Timely access to care

California law requires health plans to provide timely access to care. This means that there are limits on how long you have to wait to get healthcare appointments and telephone advice.

Santa Clara Family Health Plan (SCFHP) is committed to providing timely access to care for all members. SCFHP strives to ensure that all health services are provided in a timely manner. SCFHP will continue to notify our members of any changes or updates made regarding the current policies.

If you have a problem getting timely access to care, please call SCFHP Customer Service at 1-800-260-2055, 8:30 a.m. to 5 p.m., Monday – Friday (except holidays). TTY users call 711.

Appointment and telephone wait times

You have the right to appointments within the following time frames:

Appointment type Must get an appointment within
Urgent care appointments that do not require pre-approval
(prior authorization)
48 hours
Urgent care appointments that do require pre-approval (prior authorization) 96 hours
Non-urgent primary care appointments 10 business days
Non-urgent specialist 15 business days
Non-urgent mental health provider (non-doctor) 10 business days
Non-urgent appointments for ancillary services for the diagnosis or treatment of injury, illness, or other health condition 15 business days
Telephone wait times during normal business hours 10 minutes
Triage—24/7 services 24/7 services—No more than 30 minutes

Exceptions to timely access to care

  • The purpose of the timely access law is to make sure you get the care you need. Sometimes you need appointments even sooner than the law requires. In this case, your doctor can request that the appointment be sooner.
  • Sometimes waiting longer for care is not a problem. Your provider may give you a longer wait time if it would not be harmful to your health. It must be noted in your record that a longer wait time will not be harmful to your health.
  • If you cannot get a timely appointment in your area because there are not enough providers, your health plan must help you get an appointment with an appropriate provider.

Travel time and distance to care

SCFHP must follow travel time (minutes) and distance (miles) standards for your care. Travel time and distance standards help make sure you do not have to go too far or travel too long when you need to visit a provider.

Travel time and distance standards may be different depending on where you live. Go to “Exceptions to travel time and distance to care” to see if your ZIP Code has different standards than the ones listed in the chart below.

Provider type Travel time standard Travel distance standard
Primary Care Physician
(adult and pediatric)

Obstetrics/Gynecology
(OB/GYN) – Primary Care

Pharmacy
30 minutes from your home address 10 miles from your home address
Specialty Care
(adult and pediatric)

Obstetrics/Gynecology
(OB/GYN) – Specialist

Hospital

Mental Health
(non-psychiatry) Out-Patient Services
30 minutes from your home address 15 miles from your home address

Exceptions to travel time and distance to care:

If SCFHP is not able to provide care to you within the travel time and distance standards listed above, a different standard called an alternative access standard may be used. The chart below will show you the provider types and the ZIP Codes where alternative access standards apply. If your ZIP Code and provider type are listed, SCFHP can help you find an appointment.

Provider type Population served Zip Code Alternative travel time standard Alternative travel distance standard
Primary Care Physician Adult 95033 None 22 miles from your home address
Primary Care Physician Adult 95037 None 11 miles from your home address
Cardiology Pediatrics 95020 None 18 miles from your home address
Endocrinology Adult and Pediatrics 95020 52 minutes from your home address 29 miles from your home address
Endocrinology Adult and Pediatrics 95046 33 minutes from your home address 18 miles from your home address
ENT-Otolaryngology Adult and Pediatrics 95020 None 18 miles from your home address
HIV/Aids Infectious Disease Adult and Pediatrics 95020 52 minutes from your home address 29 miles from your home address
HIV/Aids Infectious Disease Adult and Pediatrics 95046 33 minutes from your home address 18 miles from your home address
Neurology Adult 95020 None 16 miles from your home address
Neurology Pediatrics 95020 None 18 miles from your home address
Physical Medicine and Rehab Adult and Pediatrics 95020 52 minutes from your home address 29 miles from your home address
Physical Medicine and Rehab Adult and Pediatrics 95046 33 minutes from your home address 18 miles from your home address
Pulmonology Adult and Pediatrics 95020 None 18 miles from your home address
Hospital Adult and Pediatrics 95140 90 minutes from your home address 35 miles from your home address

If you need care from a specialist and that provider is located far from where you live, you can call SCFHP Customer Service at 1-800-260-2055 (TTY: 711) to get help finding care with a specialist located closer to you. If SCFHP cannot find care for you with a closer specialist, you can request SCFHP arrange transportation for you to see a specialist even if that specialist is located far from where you live. It is considered far if you cannot get to that specialist within the SCFHP’S travel time and distance standards for your county, regardless of any alternative access standard SCFHP may use for your ZIP Code.