24-Hour Access

The Federal Health Maintenance Organization Act of 1973 requires that the participating physician group (PPG) provide uninterrupted access to medical services seven days a week, 24 hours a day. If the hospital emergency room department or the emergency room physician calls the PPG or the primary care physician (PCP), the PPG or PCP must respond within 30 minutes or the service is automatically authorized (Title 22 CCR, section 51056). PPGs and PCPs may not instruct the emergency room department or the emergency room physician to call back or wait for a physician to return the call at a later time.

PPGs are also required to provide 24-hour access for members and providers to obtain timely authorization for medically necessary care and for circumstances where the member has received emergency care and is stabilized, but the treating provider believes that the member may not be discharged safely. A physician and surgeon must be available for consultation and for resolving disputed requests for authorization.

Authorize Follow-Up Care

The PPG is responsible for authorizing any follow-up care and necessary transfers between hospitals for in-area emergencies.