Your access to care is our priority. Blue Shield of California Promise Health Plan uses the following guidelines to make ensure you have proper access to care. The Americans with Disabilities Act of 1990 ensures access for disabled members. Blue Shield of California Promise Health Plan performs audits every three years to ensure physicians adhere to care access guidelines.

Access to care guidelines for physicians

 
Standard
Description

Emergency exam

Immediately

When you call the doctor's office with an emergency medical condition, they must arrange for you to be seen right away. They may refer you to the Emergency Room or they may call 911.

Urgent doctor's exam
Within 24 hours

When you contact your doctor’s office with an urgent medical condition, we require they see you within 24 hours. We strongly urge the doctor to work you in on a walk-in basis the same day. If a situation comes up where the doctor is not available, he or she should refer you to a covering doctor or give you directions on where to be seen within 24 hours.

Sensitive services must be made available to you preferably within 24 hours, but not beyond 48 hours, of an appointment request. Sensitive services are services related to:

  • Sexual assault
  • Drug or alcohol abuse
  • Pregnancy
  • Family planning
  • Sexually transmitted diseases
  • Outpatient mental health treatment and counseling
Routine doctor, non-urgent exam
Within 10 business days
When you request an appointment for a routine, non-urgent condition, you must be given an appointment within 10 business days. A routine visit could be a follow-up for blood pressure, diabetes, or asthma.
Initial prenatal
Within 7 calendar days
You do not need a prior authorization to see an OB/GYN doctor.
Preventive care and physical exam
Within 30 business days
Any additional preventive services approved by Medicare during the contract year will be covered. Prior authorization rules apply.
Initial health assessment
Within 30 calendar days upon request
Blue Shield of California Promise Health Plan suggests you make this appointment within the first 60 days from when you became eligible. Your doctor should ask you to fill out the Initial Health Assessment form at this appointment.
After-hours care
24/7 coverage
Doctors are required by contract to give 24-hour, 7 days-per-week coverage to their patients. These standards also apply to doctors on-call.
Telephone access
 
Within 24 hours for non-emergency calls
Doctors or office staff must return any non-emergency phone calls within 24 hours of your call.  The doctor or his or her "on-call" coverage immediately must handle Urgent and emergency calls immediately. Only qualified staff can provide clinical advice (e.g.: physician, physician assistant, nurse practitioner, or registered nurse).
Waiting time in office
Up to 30 minutes after time of appointment
The maximum amount of time you will spend waiting in the office.
Seldom-used specialty services
As medically necessary
Blue Shield of California Promise Health Plan will arrange for seldom-used specialty services from specialists outside the network when determined medically necessary.
Failed appointments
Contact patient to reschedule within 48 hours
If a patient does not show up for a scheduled appointment, it must be written in the medical record on the day of the missed appointment. The doctor's office must contact the patient by mail or phone within 48 hours to reschedule the appointment. If a patient keeps missing appointments, the doctor can refer this issue to the health plan for counseling.


Access to care guidelines for specialists

 
Standard
Description

Emergency care

Immediately

If you contact the specialist’s office with an emergency need, they must contact your doctor right away, direct you to the Emergency Room, or call 911.

Urgent specialist exam
Within 48 hours

When a doctor refers you to a specialist for an urgent care medical issue (e.g., a fracture) the specialist is required to see you within 48 hours from the time the referral was first authorized.

Routine specialist visit, non-urgent exam
Within 30 calendar days
Prior authorization is required for specialists visits.
After-hours care
24/7 coverage
Doctors are required by contract to give 24-hour, 7-days-per-week coverage to members. Doctors on-call must follow the same standards of access and availability.
Telephone access
Within 24 hours for non-emergency calls
Doctors or medical office staff must return any non-emergency phone calls within 24 hours of your call. The doctor or his or her "on-call" designee must handle urgent and emergency calls immediately. Only qualified staff can give clinical advice (e.g.: physician, physician assistant, nurse practitioner, or registered nurse).
Waiting time in office
Up to 30 minutes after time of appointment
The maximum amount of time you will spend waiting in the office.
Failed appointments
Contact patient within 48 hours to reschedule
Failed appointments must be written in the medical record the day of the missed appointment, and the doctor's office is required to contact you by mail or phone within 48 hours to reschedule you. Repeated failed appointments could result in referring these issues to the health plan for counseling.