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 |
|---|---|---|---|---|
| Endocrinology | Adult & Pediatrics | 95046 | 35 minutes from your home address | 20 miles from your home address |
| Endocrinology | Adult & Pediatrics | 95020 | 50 minutes from your home address | 45 miles from your home address |
| HIV/Aids Infectious Disease | Adult | 95020 | 55 minutes from your home address | 45 miles from your home address |
| HIV/Aids Infectious Disease | Pediatrics | 95020 | 65 minutes from your home address | 40 miles from your home address |
| HIV/Aids Infectious Disease | Adult | 95046 | 35 minutes from your home address | 25 miles from your home address |
| HIV/Aids Infectious Disease | Pediatrics | 95046 | 45 minutes from your home address | 25 miles from your home address |
| HIV/Aids Infectious Disease | Pediatrics | 95037 | 140 minutes from your home address | 60 miles from your home address |
| Physical Medicine and Rehab | Pediatrics | 95020 | 55 minutes from your home address | 45 miles from your home address |
| Physical Medicine and Rehab | Pediatrics | 95046 | 35 minutes from your home address | 20 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.