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Member Frequently Asked Questions

General
Q:

Who makes up the Member Advisory Group?

Our current membership on the Member Advisory Group (MEAB) is made up of members and parents, who have children as members of this health plan, they work in social services, schools, and community agencies and provide valuable insight to the health plan. Several of them have been with CFHP for many years, they live in various parts of the city. They provide a vehicle for obtaining insight into the perceptions and expectations of health plan consumers, and to enable the health plan to tailor policies and operations to best meet the needs of the membership. Since members are key in providing input on issues related to health plan education, health plan services, and to serve in designated committees within Community First Health Plan, MEAB is an excellent way of facilitating these endeavors. If you are interested in learning about how you can participate, call Member Services at 1-800-434-2347. 

STAR Kids: 1-855-607-7827


Q:

How can I receive member materials in a different format other than print?

If you need any member materials in a different format, for example large print, Braille, audio, etc, please contact Member Services at 210-227-2347.


Q:

What is Member Portal?

Click on the Member Portal link on our homepage to register. This is a secure website. You can request an ID card, ask to change your PCP, file a complaint, or ask a question. If you are more comfortable talking to a Member Services Advocate, just call. Our phone number is (210) 358-6300. Or you can call us toll-free at 1-800-434-2347. We are here to help you!


Q:

Who is my Primary Care Provider (PCP)?

Your Primary Care Provider (PCP) is your own doctor or clinic who will provide or arrange your medical care. You can look up your PCP or any specialist in the Community First network on this website using the "Find a Provider" link.


Q:

How do I change my Primary Care Provider (PCP)?

Call Member Services at (210) 358-6262 or toll-free at (877) 698-7032 and a representative can help you designate a new primary care physician. You can also request to change your primary care physician on our website by submitting a secure request through our secure member portal. Click on "contact us," then "send a secure request to Member Services."


Q:

What is Community First's Service Area?

Community First's service area includes all of Atascosa, Bandera, Bexar, Comal, Guadalupe, Kendall, Medina and Wilson counties.


Q:

What services are available when I am outside Community First's service area?

The only services covered outside Community First’s service area are emergency room visits (E.R.). If you want to receive services outside the service area, with the exception of E.R. visits, a prior authorization will be required before the visit. Also, if medically necessary covered services are not available through Community First’s participating providers, Community First may allow you to see non-participating provider with a prior authorization request from the provider of your choice.


Q:

What do I do if I am a new member?

Once you have chosen Community First, your next step is to select who will provide the majority of health care services to you. Your primary care physician (PCP) will be the one you call when you need medical advice, when you are sick, and when you need preventive care such as immunizations. Each member may select his or her own PCP. You will select a PCP from Community First's extensive network of family or general practitioners and pediatricians. The selection of a PCP is crucial for immediate access to acute and preventive care. Click here for a list of physicians and providers in the Community First network. You can also call our Member Services department at (210) 358-6262 or toll-free at (877) 698-7032 for assistance.


Q:

When can I receive/replace my Member ID card?

CFHP makes every effort to provide new Members with ID cards as quickly as possible once enrollment information is transmitted. However, during the time of enrollment processing, Members and providers may verify eligibility through CFHP’s secure portal. Member information is updated daily.

If you need to request a replacement or additional ID card, you may do so through our secure web portal. You may also call Member Services at (210) 227-2347 or toll-free at 1-800-434-2347.


Q:

Is a referral or authorization required to see a specialist?

Community First does not require a referral to see a specialist. Some specialists may require a referral from your PCP in order to see you. Additionally, some services require a pre-authorization from Community First before you receive services. Your PCP will take care of this request for you. You can call Member Services to find out if a certain service requires authorization.



Some services may require a referral:

  • Behavioral health services
  • OB/GYN services
  • Vision exams from an optometrist


Call Member Services if you need assistance finding a provider or to help you schedule an appointment at (210) 227-2347 or toll-free at 1-800-434-2347.


Q:

What emergency, after hours, and urgent care services are available?

Emergency Care:
In a medical emergency, call 9-1-1 or go to the nearest emergency room. Call your primary care physician as soon as possible after you get care. Your doctor can help you arrange follow-up care.

Emergency medical condition means: a medical condition manifesting itself by acute symptoms of recent onset and sufficient severity (including severe pain), such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical care could result in:

  1. Placing the patient's health in serious jeopardy
  2. Serious impairment to bodily functions
  3. Serious dysfunction of any bodily organ or part
  4. Serious disfigurement
  5. In the case of a pregnant woman, serious jeopardy to the health of a woman or her unborn child.

Urgent Care:
Urgent medical care is when you are sick or hurt, and need help within 24 hours to keep from getting worse. You should call your Primary Care Physician, who will direct you based on your symptoms. You may also call Community First. We have a nurse advice line, available 24 hours, 7 days a week. They can give you guidance based on your situation.

After Hours Care:
Illnesses and injuries sometimes occur after normal office hours. If you get sick or injured after hours, you should call your primary care provider. He or she has made arrangements to have their calls answered 24 hours a day, 7 days a week. You can also call Community First Member Services. We have nurses who can help you 24 hours a day, 7 days a week. The nurse might refer you to an urgent care center, the hospital emergency room, or to a doctor who is open after routine office hours. The nurse might also give you home advice.


Q:

What do I do if I get a bill?

Call Member Services at (210) 358-6262 or toll-free at (877) 698-7032 for assistance. We can help you figure out what to do. Be sure to have a copy of the bill in front of you when you call.



Please note, some CFHP in-network facilities (hospitals, emergency clinics, outpatient clinics, ambulatory surgical centers, or other facility providing health care services) may have a facility-based physician or a facility-based health care practitioner, such as a radiologist, an anesthesiologist, a pathologist, an emergency department physician, or a neonatologist that is not included in the network. CFHP pays these providers under a fee schedule. These non-participating facility-based physicians and non-participating facility-based health care practitioners may balance bill the enrollee, which means receiving a bill from a provider for the reminder of the charges billed by the provider, for amounts not paid by the enrollee’s health benefit plan (Texas Insurance Code §1456.001,003).


Q:

How can I contact interpreter services?

Please call member services at (210) 227-2347 to contact interpreter services. 


Q:

What is the name of the pharmacy vendor (for prescription benefits)?

Your health plan includes a 3-tier prescription drug benefit, which is administered by Community First and our Pharmacy Benefit Manager (PBM), Navitus Health Solutions. Please click here for more information about your pharmacy benefits.


STAR Kids/STAR Medicaid
Q:

How do I file a complaint?

If you have a complaint, please call us toll-free at:

STAR Medicaid: 1-800-434-2347, option 3 or 210-358-6060
STAR KIDS: 1-855-607-7827 or 210-358-6403

You may also send us a written complaint request to:

Community First Health Plans
12238 Silicon Drive, Suite 100
San Antonio, TX 78249
Attention: Member Services Resolution Unit

A Community First Member Services Representative can help you file a complaint. You may also send us a secure request on our website through the Member Portal. We will let you know we received your complaint, by mail, within five days and send you a resolution letter within 30 days. If you are not happy with the outcome, you may file an appeal.

File a complaint:

If you get benefits through Medicaid's STAR program, call your medical plan first. If you don't get the help you need there, you should do one of the following:

a. Call Medicaid Managed Care Helpline at 1-866-566-8989 (toll free).

b. Online: Online Submission Form (only works in Internet Explorer)

c. Mail: Texas Health and Human Services Commission
Office of the Ombudsman, MC H-700
P.O. Box 13247
Austin, TX 78711-3247

d. Fax: 1-888-780-8099 (Toll-Free)


Q:

How can I choose a Primary Care Provider (PCP)?

You can go to Find a Provider page and select your plan to choose a PCP. After your selection, you must call member services at (210) 227-2347 to update your PCP. 

Note: Please remember to have the name of your new PCP accessible when contacting member services.

For any dental questions, please contact your dental plan: 

DentaQuest - 1-800-516-0165

MCNA - 1-855-691-6262


Q:

How can I get a breast pump?

Breast pumps are a covered benefit, which covers a manual or non- hospital grade electric breast pump. In order to get a breast pump, you will have to get a prescription from your physician and take it to a participating medical supply provider. If you need help finding a participating medical supply provider, click here.


Q:

What extra benefits does a member of Community First get?

As a STAR member, you have access to the following extra STAR benefits including:

  • 24-Hour Nurse Advice Line
  • Bus tokens for doctor visits and health education classes
  • Extra vision benefits
  • A prescription discount card your whole family can use
  • Free sports and school physicals
  • Weight management program
  • Smoking cessation program
  • Emergency advice kit
  • Asthma kit
  • Personal visits for pregnant women
  • Member gift card programs


Call us at 1-800-434-2347 to learn more about these and other benefits.


Q:

What should I do if I want to file an appeal?

If you submitted a complaint and you are not happy with the resolution of your complaint, which affects your ability to receive benefit coverage, access to care, access to services or payment for care of services, you have the right to submit an appeal.

Call us:

Our toll-free number is 1-800-434-2347, option 3 (STAR Medicaid) or 1-855-607-7827 (STAR Kids) to request an appeal. We will send you an appeal form to fill out and return to Community First. We must receive a signed, written appeal form from you to begin the process of your appeal. Once your written complaint appeal is received at Community First, an acknowledgement letter will be mailed out to the member or Legal Authorized Representative (LAR) within five business days. The member or LAR may:

  • Present alternative expert testimony;
  • Submit relative documents to support request for complaint appeal;
  • Submit any additional pertinent information that was not previously considered;
  • An Appeal Committee meets and a final decision is rendered. 
  • A resolution letter is mailed to the Member within 30 calendar days from the date of the receipt of the complaint appeal.

If complainant has any questions or concerns during the appeal process, please contact one of the following:

STAR Member Services department (210) 358-6063 or toll-free 1-800-434-2347, option 3
STAR Kids Member Services department: (210) 358-6403 or toll free 1-855-607-7827
STAR Kids Service Coordinators: (210) 358-6403 or toll free 1-855-607-7827
STAR Kids Member Advocates: (210) 358-6403 or toll free 1-855-607-7827

If the appeal is for an emergency or a denial of continued hospitalization, the appeal will be forwarded to the Health Services Management Resolution Unit.

Appeals not related to an Adverse Determination review, but related to the need for clinically urgent health care services will be addressed within three business days, depending on the severity and/or urgency of the appeal. The member will be notified by telephone of the actions taken by the health plan to resolve the appeal within three business days. Final resolution to address the appeal will be mailed within timeframe outlined in this policy.

At any time, you may file a complaint through Health and Human Services Commission by writing or calling:

Health and Human Services Commission
Health Plan Operations -H320
P.O. Box 85200
Austin, TX 78708-5200
ATTN: Resolution Services

Toll-free telephone number: 1-866-566-8989

Email:HPM_Complaints@hhsc.state.tx.us


Q:

How can I request a Fair Hearing?

If a member disagrees with Community First Health Plans (CFHP) decision, you have the right to ask for a Medicaid fair hearing. Members can contact us at our toll free number STAR Medicaid: 1-800-434-2347; STAR Kids 1-855-607-7827, or send a letter to the health plan at 12238 Silicon Drive, Suite 100, San Antonio, TX 78249 to ask for a State Fair Hearing. A State Fair Hearing can be requested at any time. It can be during or after CFHP’s appeals process. After contacting us, a package of information will be mailed out letting you know the date, time and location of the hearing. Members may call STAR Medicaid: 1-800-434-2347 or STAR Kids: 1-855-607-7827 to get more information regarding the process or status questions of Fair Hearing Process.

Fair Hearing Document PDF


Q:

Who do I contact if I have questions regarding my vision benefits?

Please contact member services regarding your vision eligibility and benefits at 210-227-2347. Or follow this link if you are looking for your provider contracted with your vision plan. 


Q:

Who do I contact if I have questions about my dental benefits?

Please contact your dental plan:

DentaQuest - 1-800-516-0165

MCNA - 1-855-691-6262

If you have any additional questions regarding your eligibility, please contact member services at (210) 227- 2347.


CHIP
Q:

How can I choose a Primary Care Provider (PCP)?

You can go to Find a Provider page and select your plan to choose a PCP. After your selection, you must call member services at (210) 227-2347 to update your PCP. 

Note: Please remember to have the name of your new PCP accessible when contacting member services.

For any dental questions, please contact your dental plan: 

DentaQuest - 1-800-516-0165

MCNA - 1-855-691-6262


Q:

What extra benefits does a member of Community First get?

As a CHIP member, you have access to the following extra CHIP benefits including:

  • 24-Hour Nurse Advice Line
  • Bus tokens for doctor visits and health education classes
  • Extra vision benefits
  • A prescription discount card your whole family can use
  • Free sports and school physicals
  • Weight management program
  • Smoking cessation program
  • Emergency advice kit
  • Asthma kit
  • Member gift card programs


Call us at 1-800-434-2347 to learn more about these and other benefits.


Q:

What should I do if I want to file an appeal?

If you submitted a complaint and you are not happy with the resolution of your complaint, you have the right to submit an appeal.

Call us at 210-358-6300, or toll-free number at 1-800-434-2347, option 4 to request an appeal.

We will send you an appeal form to fill out and return to Community First Health Plans. We must receive a signed appeal form from you to begin the process of your appeal. Once your written appeal is received at Community First, an acknowledgement letter will be mailed out to you or your designated representative within five business days. The member or designated representative may:

  • Appear in person before the Appeal Panel, at the site where the Complainant normally receives health care services or at another site agreed to by the Complainant;
  • Submit a written appeal to the Complainant Appeal Panel, if Complainant does not wish to appear in person;
  • Have a designated representative appear before the Appeal Panel if the member is a minor or disabled;
  • Present alternative expert testimony;
  • Request the presence of and question any person responsible for making the decision which resulted in the appeal.

The Complainant will be provided documentation at least 5 business days prior to the date of the appeal panel hearing, unless the Complainant agrees otherwise. Notification will include:

  • Documentation to be presented to the Complaint Appeal Panel by CFHP staff;
  • The specialty of any physicians or providers consulted during the investigation; and
  • The name and affiliation of each Community First representative panel.

The Complaint Appeal Panel makes a final decision which is mailed to the complainant within 30 calendar days from the date of receipt of the appeal. The letter will contain information that will support the final decision. If Complainant has any questions or concerns during the appeal process, they may contact our Member Services department at 210-358-6300 or 1-800-434-2347, option 4 for assistance.

If Complainant is dissatisfied with the resolution of the appeal, the Complainant may file a complaint though the Texas Department of Insurance (TDI) by writing or calling:

Texas Department of Insurance
P.O. Box 149104
Austin, Texas 78714-9104

Toll Free telephone number: 1-800-252-3439

Web:www.tdi.state.tx.us

Email:consumerprotection@tdi.state.tx.us

*Complainant may file a complaint through the Texas Department of Insurance at any time during this process.


Q:

Who do I contact if I have questions regarding my vision benefits?

Please contact member services regarding your vision eligibility and benefits at 210-227-2347. Or follow this link if you are looking for your provider contracted with your vision plan. 


Q:

Who do I contact if I have questions about my dental benefits?

Please contact your dental plan:

DentaQuest - 1-800-516-0165

MCNA - 1-855-691-6262

If you have any additional questions regarding your eligibility, please contact member services at (210) 227- 2347.


Q:

How do I file a complaint?

If you have a complaint, please call us at (210) 358-6300, or toll-free at 1-800-434-2347, option 4. You may also send a written request to:

Community First Health Plans
12238 Silicon Drive, Suite 100
San Antonio, TX 78249
Attention: Member Services Resolution Unit

A Community First Member Services Representative can help you file a complaint. You may also send us a secure request on our website through the Member Portal. We will let you know we received your complaint, by mail, within five days and send you a resolution letter within 30 days. If you are not happy with the outcome, you may file an appeal.

In addition, CHIP members MUST return this complaint form to file a written complaint. 



CHIP Perinatal Program
Q:

Who is the Prenatal Care Provider?

Your prenatal care network provider is an OB/GYN of your choice. Please keep in mind that this provider has to be contacted with CFHP for services to be covered under the health plan. Click here to see a list of the prenatal care providers and the hospitals where you will deliver you baby.

You do not need a referral to call the doctor or clinic of your choice.


Q:

What extra benefits does a member of Community First get?

As a CHIP Perinatal member, you have access to the following extra CHIP Perinatal benefits including:

  • 24-Hour Nurse Advice Line
  • Bus tokens for doctor visits and health education classes
  • A prescription discount card your whole family can use
  • Free flu shots for CHIP Perinatal members
  • Personal visits for pregnant women

Call us at 1-800-434-2347 to learn more about these and other benefits.


Q:

What should I do if I want to file an appeal?

If you submitted a complaint and you are not happy with the resolution of your complaint, you have the right to submit an appeal.

Call us at 210-358-6300, or toll-free number at 1-800-434-2347, option 4 to request an appeal.

We will send you an appeal form to fill out and return to Community First Health Plans. We must receive a signed appeal form from you to begin the process of your appeal. Once your written appeal is received at Community First, an acknowledgement letter will be mailed out to you or your designated representative within five business days. The member or designated representative may:

  • Appear in person before the Appeal Panel, at the site where the Complainant normally receives health care services or at another site agreed to by the Complainant;
  • Submit a written appeal to the Complainant Appeal Panel, if Complainant does not wish to appear in person;
  • Have a designated representative appear before the Appeal Panel if the member is a minor or disabled;
  • Present alternative expert testimony;
  • Request the presence of and question any person responsible for making the decision which resulted in the appeal.

The Complainant will be provided documentation at least 5 business days prior to the date of the appeal panel hearing, unless the Complainant agrees otherwise. Notification will include:

  • Documentation to be presented to the Complaint Appeal Panel by CFHP staff;
  • The specialty of any physicians or providers consulted during the investigation; and
  • The name and affiliation of each Community First representative panel.

The Complaint Appeal Panel makes a final decision which is mailed to the complainant within 30 calendar days from the date of receipt of the appeal. The letter will contain information that will support the final decision. If Complainant has any questions or concerns during the appeal process, they may contact our Member Services department at 210-358-6300 or 1-800-434-2347, option 4 for assistance.

If Complainant is dissatisfied with the resolution of the appeal, the Complainant may file a complaint though the Texas Department of Insurance (TDI) by writing or calling:

Texas Department of Insurance
P.O. Box 149104
Austin, Texas 78714-9104

Toll Free telephone number: 1-800-252-3439

Web:www.tdi.state.tx.us

Email:consumerprotection@tdi.state.tx.us

*Complainant may file a complaint through the Texas Department of Insurance at any time during this process.


Q:

How do I file a complaint?

If you have a complaint, please call us at (210) 358-6300, or toll-free at 1-800-434-2347, option 4. You may also send a written request to:

Community First Health Plans
12238 Silicon Drive, Suite 100
San Antonio, TX 78249
Attention: Member Services Resolution Unit

A Community First Member Services Representative can help you file a complaint. You may also send us a secure request on our website through the Member Portal. We will let you know we received your complaint, by mail, within five days and send you a resolution letter within 30 days. If you are not happy with the outcome, you may file an appeal.

In addition, CHIP members MUST return this complaint form to file a written complaint. 



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