You should ask about the contract status of the providers from whom you receive treatment, especially when you are referred by your PCP to a specialty care physician and when you receive services at a participating hospital. Some facility-based physicians or other health care practitioners, such as anesthesiologists, pathologists, and radiologists, may not be included in Community First's network and may balance bill you for amounts not paid by Community First.
After-Hours Care:
Illnesses and injuries often do not strike during normal office hours. You may call your PCP's office 24 hours a day.
Urgent Care Services:
In the event of an urgent situation (illness or injury) that is severe or painful enough to require assessment and/or treatment within 24 hours, you should contact your PCP, who will direct you based on your symptoms. Additionally, members may call NurseLink, Community First's 24-hour nurse advice line, for guidance about urgent and emergency care during all non-business hours. You may reach NurseLink by calling (210) 358-3000 or toll-free (800) 950-5803.
Emergency Care Services:
If you have any questions regarding whether a situation constitutes a medical emergency, please contact your PCP who will direct you based on your symptoms. Additionally, members may call NurseLink, Community First's 24-hour nurse advice line. You may reach NurseLink by calling (210) 358-3000 or toll-free (800) 950-5803.
The member's PCP should be informed of the emergency care within 24 hours, or as soon as reasonably possible, so that he or she can manage the member's follow-up care.
If medically necessary covered services are not available through Community First's participating providers, Community First will allow, upon the request of a participating provider, a referral to a non-participating provider. Before Community First denies such referral, you may request a review by a specialist of the same or similar specialty as the type of physician or provider to whom a referral is requested.
Only emergency care services are covered outside the Community First's network and/or service area, unless medically necessary covered services are not available through Community First's network of participating providers, or in the case of court-ordered dependent coverage.
As a value-added service, we are pleased to offer members an Enhanced Travel Network to access urgent and emergency care while traveling. You and your covered family members have the option to see a First Health network provider in an urgent or emergency care situation while traveling outside of the Community First HMO service area. If you are in need of urgent or emergency care while you are traveling outside of the service area, you may contact First Health at (800) 226-5116 to locate a provider.
ERS cannot and does not guarantee the length of time that a specific type of “Value-Added” product shall be offered. Any questions or concerns about these products should be directed to the sponsoring HMO.
You may pay a premium for your group plan coverage. The premium amount and payment arrangements are made through your employer. Your employer will agree with Community First on a fixed price per each member of your group and will determine how much of that cost to pass along to you. In addition to any payroll deduction your employer may impose, you will be responsible for appropriate copays and/or percentages of fees connected with benefits as described in the benefit tables, up to the identified out-of-pocket maximum.
If you receive health care services that are not a covered benefit, or you do not obtain the referrals and/or authorizations outlined below, you will be financially responsible for the entire cost of service. However, Community First's participating physicians and providers will look only to Community First and not to you for payment for covered services except as set forth in the Certificate of Group Health Coverage.
Community First will arrange or provide for benefits for covered services and supplies. A written referral and/or pre-authorization by the PCP and/or Community First is required for payment of most covered services and/or supplies rendered by other participating providers and all non-participating providers. Exceptions apply in the case of a medical emergency or when accessing the services of a properly credentialed, participating obstetrician or gynecologist or behavioral health provider.
Pre-authorization is granted on the condition that the member is eligible for covered services at the time the covered services are received. Pre-authorization will be denied if the requested supply or service is not a covered service or supply. If you have any questions about whether a covered service or supply requires pre-authorization, contact your PCP or Community First's Member Services Department.
Some covered services and/or supplies may require medical review for medical necessity and/or appropriateness prior to pre-authorization.
Covered services: All covered services must be furnished to a member:
by a PCP;
by another participating provider and authorized by a PCP or Community First;
by a non-participating provider and authorized by a PCP or Community First;
by a participating specialty care physician approved by Community First's Medical Director to perform the services of a PCP pursuant to a request of a member with a chronic, disabling, or life-threatening illness; or
by a participating obstetrician or gynecologist as described above or a participating behavioral health provider as described above.
It is your responsibility to secure a referral from your PCP to see specialists and to undergo hospitalizations, outpatient surgery, and diagnostic procedures. Written referral is required for payment of services and supplies rendered by other participating providers.
If medically necessary covered services are not available through a participating provider, Community First will, at the request of a participating provider and within a reasonable time period, allow referral to a non-participating provider and will fully reimburse the non-participating provider at the usual and customary rate or at a negotiated rate. Before such a requested referral can be denied, Community First must have the request reviewed by a specialist of the same or similar specialty as the physician or provider to whom the referral is requested.
Community First will notify you no less than 30 days in advance if a participating physician or other provider treating you is going to be leaving the Community First network. If the physician or other provider is treating you under a "special circumstance," and the treating physician or provider makes the request, then Community First will continue to compensate the physician or other provider, on your behalf, for up to 90 days. "Special circumstance" means a condition such that your physician or provider reasonably believes discontinuation of care could cause harm to you. Examples include:
A person who has a disability;
A person with an acute condition;
A person with a life-threatening Illness; or
A person who is past the twenty-fourth week of pregnancy. In this case, services would extend through delivery of the child, immediate postpartum care, and the follow-up checkup within the first six weeks of delivery.
General. Members are required to submit all complaints through Community First's internal complaints and appeals process, which we have outlined for you below. Community First encourages the informal resolution of complaints, especially if complaints result from misinformation, misunderstanding, or lack of information. Community First will not retaliate against you or a contract holder, including cancellation of coverage or refusal to renew coverage, simply because the contract holder, you, or person acting on behalf of the contract holder or you, has filed a complaint against Community First, or appealed a Community First decision. Community First will not retaliate against any participating physician or provider, including termination of or refusal to renew a contract, simply because a participating physician or provider has, on your behalf, filed a complaint against Community First or appealed a Community First decision.
At any time, you have the right to contact the Texas Department of Insurance toll free at (800) 252-3439.
Where to File a Complaint. Complaints/appeals should be directed to Community First's Member Services Department at (210) 358-6262 or toll free (800) 434-2347, or in writing to: 12238 Silicon Drive, Suite 100 San Antonio, TX 78249
Process for Complaint Resolution
Complaints will be handled in the following manner:
Step Action
You, or someone acting on your behalf, notifies Community First orally, or in writing, of a complaint.
If we have received a written complaint, we will send you a letter acknowledging receipt of your complaint within five (5) working days of Step 1. This letter will also include the date Community First received the complaint, as well as a description of the complaint, appeals process, and time frames. If we have received an oral complaint, we will include a one-page complaint form, along with the above information, which should be returned immediately for prompt resolution of the complaint.
Community First will investigate the complaint and send you or your designated representative a letter explaining the resolution of your complaint along with a full description of the process for appeal, including time frames. Community First will acknowledge, investigate, and resolve your complaint within 30 calendar days from the date we receive your written complaint or your completed complaint form.
Investigation and resolution of complaints relating to emergency care or denials of continued hospital stays will be concluded in accordance with the medical or dental immediacy of the case, but will not exceed one (1) working day from the date the complaint is received by Community First.
Appeals Process
Appeals will be handled in the following manner:
Step Action
If you are not satisfied with Community First's resolution of your complaint, you or your designated representative may notify Community First orally or in writing of your wish to appeal our decision.
Community First will send you a letter acknowledging receipt of your appeal within five (5) working days of Step 1. This letter will include the date Community First received the appeal. If your appeal was received orally, we will include a one-page appeal form, as well as the following information:
Your right to appear in person before the Appeals Panel;
Your right to have a designated representative appear before the Panel if the member is a minor or disabled;
Your right to present written or oral information;
Your right to present alternative expert testimony;
Your right to request the presence of and question any person responsible for making the decision resulting in the Appeal;
Community First will schedule your hearing before the Appeals Panel where you or your dependent normally receive health care services within the service area, unless you and Community First agree to another site. The Appeals Panel will consist of individuals appointed by Community First. The panel consists of equal numbers of Community First staff, physicians, or other providers; and members. No member serving on the panel may have been previously involved in the disputed decision that is the subject of the appeal. All physicians or other providers serving on the panel must have experience in the area of care that is in dispute and must be independent of the physician(s) or provider(s) who made any prior determination(s). If specialty care is in dispute, the Appeals Panel will include an additional person who is a specialist in the field of care to which the appeal relates. Members serving on the Appeals Panel may not be employees of Community First.
No later than five (5) working days before the hearing, unless you agree otherwise, Community First shall provide you or your designated representative:
any documentation that Community First staff will present to the Panel;
the specialization of any physicians or providers consulted during the investigation; and,
the name and affiliation of each Community First representative on the panel. Relevant documents are reviewed by the Appeals Panel and considered along with relevant presentations and discussions. You or your designated representative and Community First will be allowed to present any relevant information and have witnesses or counsel present.
The Appeals Panel renders a recommendation and Community First notifies you or your designated representative of Community First's decision regarding your appeal.
Community First will complete the appeals process no later than 30 calendar days after the date your written request for an appeal, or your completed appeal form, is received by Community First. Any recommendation from an Appeals Panel will be obtained within this timeframe.
Investigation and resolution of appeals relating to ongoing emergencies, or denials of continued Hospital stays, will be concluded in accordance with the medical or dental immediacy of the case, but will not exceed one (1) working day from the date the appeal is received by Community First.
Due to the ongoing emergency or continued hospital stay, Community First will provide, at the request of the member and in lieu of an Appeals Panel, a review by a physician or provider who has not previously reviewed the case and is of the same or similar specialty as typically manages the medical condition, procedure, or treatment under discussion for review of the appeal. The physician or provider reviewing the appeal may interview you or your designated representative and will render a decision on the appeal. Initial notice of the decision may be delivered orally if followed by written notice of the determination within three (3) working days. Investigations and resolution of appeals after emergency care has been provided will be conducted according to the process outlined in Steps 1-6 above.
At any time, you have the right to contact the Texas Department of Insurance at (800) 252-3439.
Arbitration. If, after completion of the process described above, you remain dissatisfied, you may exercise your right to submit the matter to arbitration, which is final and binding. All claims, disputes, controversies, and other matters in question related to any of the terms of the Certificate of Group Health Coverage will be arbitrated and the arbitration proceeding will be conducted pursuant to the Texas Arbitration Act. Notice of the demand for arbitration will be made in writing and filed with Community First subject to this provision, and the demand will be made within a reasonable time not to exceed 30 days after the process described in Sections 3 through 5 above has been exhausted.
Maintenance of Records. Community First will maintain a record of each complaint and/or appeal as well as any proceedings and any actions taken on a complaint and/or appeal for three (3) years from the date of receipt of a complaint. You may obtain a copy of the record on your complaint, appeal, and any proceedings.
Process for Appealing an Adverse Determination. An adverse determination is a determination by Community First, or its Utilization Review Agent, that the health care services furnished or proposed to be furnished to a member are not medically necessary or not appropriate. You, your designated representative, or your provider of record may appeal an adverse determination orally or in writing. Appeals of adverse determinations will be handled in the following manner:
Step Action
Within five (5) working days from receipt of the appeal, Community First will send the appealing party a letter acknowledging the date of Community First's receipt of the appeal. This letter will include a list of documents that must be submitted for review to Community First.
When Community First receives an oral appeal of an adverse determination, Community First will send the appealing party a one-page appeal form.
The appealing party will be provided, upon request, with a clear and concise statement of the clinical basis for the adverse determination.
Emergency care denials and denials of continued stays for hospital patients may follow an expedited appeal procedure. This procedure includes a review by a health care provider who has not previously reviewed the case, and who is of the same or a similar specialty as typically manages the medical condition, procedure, or treatment under review. The time frame in which such an expedited appeal must be completed will be based on the medical or dental immediacy of the condition, procedure, or treatment, but will not exceed one (1) working day following the date that the appeal, including all information necessary to complete the appeal, was made to Community First.
After Community First has sought review of the appeal of the adverse determination, we will notify you or your designated representative, and your provider of record explaining the resolution of the appeal. Community First will provide written notification to the appealing party as soon as practical, but no later than 30 days after we receive the appeal.
A physician will make all appeal decisions. If the appeal is denied, and within ten (10) working days the health care provider sets forth, in writing, good cause for having a particular type of a specialty provider review the case, the denial will be reviewed by a health care provider in the same or similar specialty as typically manages the medical, dental, or specialty condition, procedure, or treatment under discussion for review. Such specialty review will be completed within 15 working days of receipt of the request.
Process for Requesting Independent Review of an Adverse Determination
Step Action
You, your designated representative, or your provider of record, will be notified at the time of the denial of the appeal of an adverse determination of your right to have your appeal reviewed by an Independent Review Organization (IRO). You may only seek independent review in the case of an adverse determination.
Community First will provide to you, your designated representative, or your provider of record, with the prescribed form. The form must be completed and returned to Community First in order to begin the independent review process.
In a circumstance involving a life-threatening condition, you are entitled to an immediate appeal to an IRO and are not required to comply with the procedures for an internal review of an adverse determination. In these circumstances, you, your designated representative, or your provider of record, may contact Community First by telephone to request the review and provide the required information.
There is no right of appeal of the IRO determination by you, your designated representative, your provider of record, or Community First. This appeals process does not prohibit you from pursuing other appropriate remedies, including injunctive relief, a declaratory judgment, or relief available under law, if the requirement of exhausting the appeal process places your health in serious jeopardy.
PCP Selection Once you have chosen Community First, your next choice is to select who will provide the majority of your and your eligible dependents' health care services. Your PCP will be the one you call when you need medical advice, when you are ill, and when you need preventive care, such as immunizations. Each covered person may select his or her own PCP from the Community First participating provider directory. Primary medical care includes the following medical specialties: internal medicine, general, pediatrics, family practice, and OB/GYN.
Should you have a chronic, disabling, or life-threatening illness, you may apply to Community First's Medical Director to use a participating specialty physician as a PCP, provided that (1) the request includes information specified by Community First, including certification of medical need, and is signed by you and the participating specialty physician interested in serving as the PCP; (2) the participating specialty physician meets, and agrees to abide by, the Community First requirements for PCPs; and (3) the participating specialty physician is willing to accept the coordination of all of your health care needs.
If your request is denied, you may appeal the decision through Community First's established complaint and appeals process. Should your request be approved, the new designation will not be retroactive and will in no way reduce the amount of compensation owed to the original PCP prior to the date of the new designation.
Changing Your PCP
Community First believes that a strong PCP-member relationship is critical. However, we also realize that there may be a need for a member to change his/her PCP. If you must change your PCP, you may do so by calling Community First's Member Services Department. Requests for changes received on or before the 15th of the month will take effect on the first day of the following month. Requests for changes received after the 15th will take effect the first day of the second month following the change request.
For example, if you request a change on or before August 15, the change will become effective September 1. If you request a change on or after August 16, the change will become effective October 1.
The examples and information used in this correspondence are provided for general information and guidance only and are not intended to, nor do they, provide medical advice, diagnosis or treatment for any specific individual or any specific case. You should contact the respective GBP Vendor or your physician to discuss any concerns you may have relating to your specific circumstances or any of the matters discussed herein as they may relate to your own health and welfare.
ATTENTION: FEMALE ENROLLEES!
Selection of an Obstetrician/Gynecologist
A woman entitled to coverage will be permitted direct access to the health care services of a participating obstetrician or gynecologist without a referral by the woman's primary care physician (PCP) or pre-authorization or pre-certification by Community First to include, but not be limited to, the following:
one well-woman examination per year;
care related to pregnancy;
care for all active gynecological conditions; and
diagnosis, treatment, and referral to a Participating Specialty Care Physician for any disease or condition within the scope of the professional practice of a properly credentialed obstetrician or gynecologist, including treatment of medical conditions concerning the breasts.
