L.A. Care

1.     Member Services Department Call Service:
a.   Speed of Telephone Answer: The maximum length of time for Member Service Department staff to answer the telephone.

b.  Call Abandonment Rate

• <30 seconds

• Not to exceed 5%

PCP

2.     Preventive Exams:
A periodic health evaluation for a member with no acute medical problem, including:

• Initial Health Assessment and Initial Staying Healthy Behavioral Risk Assessment

• For members under the age of 18 months within 120 calendar days following the date of enrollment or within periodicity timelines established by the American Academy of Pediatrics (AAP) for ages two and younger whichever is less.
• For members 18 months of age or older upon enrollment within 120 calendar days of enrollment

• First Prenatal Visit

• Within 14 calendar days from request
• Within 7 calendar days for Healthy Families and Healthy Kids membership

• Routine preventive health examination.

• Within 30 calendar days from request

• EPSDT/CHDP

• 14 calendar days

3.     Routine Primary Care (non-urgent):
Services for a patient who is symptomatic but does not require immediate diagnosis and/or treatment.

• Within 10 business days of request

4.     Urgent Care:
Services for a non-life threatening condition that could lead to a potentially harmful outcome if not treated in a timely manner.

• Within 48 hours of request

5.     Emergency:
Services for a potentially life threatening condition requiring immediate medical intervention to avoid disability or serious detriment to health.

• Immediate, 24 hours a day, 7 days per week

6.     Office Waiting Room Time:
The time a patient with a scheduled medical appointment is waiting to see a practitioner once in the office.

• < 45 minutes

7.     Speed of Telephone Answer (Practitioner’s Office):
The maximum length of time for practitioner office staff to answer the phone.

• 30 seconds

8.     After Hours Calls:

Automated systems:

• Must provide emergency instructions
• Offer a reasonable process to contact the PCP, covering physician or other "live" party
• If process does not enable the caller to contact the PCP or covering physician directly, the “live” party must have access to a physician for both urgent and non-urgent calls.
• Professional exchange staff:
• Must provide emergency instructions
• Must have access to a physician for both urgent and non-urgent calls

9.     Call Return Time:
The maximum length of time for PCP or on-call physician to return a call after hours.

• 30 minutes

SCP

1.     Routine Specialty Care:

• Within 30 calendar days of request

BHP

1.     Routine Behavioral Health Care

• Within 10 calendar days of request

2.     Urgent Care

• Within 48 hours of request

3.     Non-life-threatening emergency

• Within 6 hours of hours

4.     Emergency:
Services for a potentially life threatening condition requiring immediate medical intervention to avoid disability or serious detriment to health.

• Immediate, 24 hours a day, 7 days per week

5.     Behavioral Health Telephone Responsiveness

• Quarterly average speed of answer for screening and triage calls.
• Quarterly average abandonment rate for screening and triage calls.

• < 30 seconds

• < 5%