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Providers Frequently Asked Questions

General
Q:

Who forms the Provider Advisory Group?

The provider office staff advisory committee (POSAC) consists of PCP, specialty, and other provider representatives to discuss and collaborate on issues that have an impact on our providers and members. To find out more information about joining the CFHP POSAC, please contact Network Management at (210) 358-6030. 

Community First is seeking physicians and LTSS providers to participate on the new STAR Kids Provider Advisory Board. The Board is a subcommittee of the health plan Quality Improvement Committee. This committee is dedicated to quality patient care and improved health outcomes for health plan members. The goal of our new Advisory Board is to improve and/or maintain the health status of our STAR Kids members through improvement of quality care and services. Clinical and care guidelines specific to the STAR Kids program will be reviewed and approved by the Advisory Board. For questions or to express your interest in participating in the STAR Kids Provider Advisory Board please contact:

Susan Lomba
Exec. Dir., Quality Management & Accreditation
Office: (210) 358-6376
Email: slomba@cfhp.com


Q:

How do I apply to become a Network Provider?

If you would like to apply to become a Network Provider, please fill out the letter of interest


Q:

What is the Provider Services hotline number?

The Provider Services hotline number is (210)358-6030.


Q:

What should I do if I want to file a complaint or an appeal?

To file a provider complaint or appeal, please use the following contact information:

Contact: 210-358-6294 or (210) 358-6030

Email: nmcfhp@cfhp.com

Fax: (210) 358-6199

State inbox contact: HPM_Complaints@hhsc.state.tx.us 


Q:

What is Cultural Competency?

Community First Health Plans (CFHP) maintains a comprehensive Cultural Competency plan, which includes education and outreach activities that are culturally sensitive, meet the language and literacy needs of the targeted population, and will work to minimize communication and physical access barriers. The purpose is to effectively provide, equitable, understandable and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy and other communication needs. The manner in which services are provided will recognize value, affirm and respect the worth of the individual and protect and preserve personal dignity.

CFHP provider manuals include information regarding provider access to linguistic and interpreter services available through CFHP and information regarding bilingual health plan and Member materials available for provider use.


Q:

​Are members assigned a PCP?

Members are required to select a PCP upon enrollment.


Provider Portal
Q:

Is there any customer support for the Web portal?

First-time providers are given a formal training/tour of our Web portal. Contact your provider relations representative for any issues, concerns or question.


Q:

How do I apply for access to the Web portal?

Providers must submit a completed Web portal agreement. Completed agreements will then be assigned a username and password. Contact your provider relations representative to obtain a Web portal agreement.


Q:

Can you request on-line authorization/referrals?

You may request on-line authorizations/referrals and may check the status of your request through the AcuExchange System. You must first request access from our Network Management department by calling (210) 358-6030 or (800) 434-2347.


Q:

Can you submit claims via the Web portal?

On-line claims submission is now available through the Provider Web Portal under Claim MD. You may now also appeal a claim through the secure Web portal. 


Q:

What kind of functions can I perform on the Web portal?

Verify member's eligibility/status, claim status inquiry, EOP inquiry, provider panel rosters, on-line provider search directory, and Texas Health Steps exams (new, due, overdue).


CHIP Perinatal
Q:

How can I get information regarding the Texas Medicaid/ CHIP Vendor Drug Program?

To obtain information regarding the Texas Medicaid/ CHIP Vendor Drug Program, click here.


Q:

What services are not covered?

A mother's hospital visit for services not related to labor with delivery, such as a broken arm or false labor. Specialty care for the mother, such as care for asthma, heart conditions, mental health or substance abuse.


Q:

What are some of the benefits of the program?

  • Up to 20 perinatal visits Prescriptions such as prenatal vitamins
  • Labor with delivery of the child depending on your income, some women may be asked to apply for Emergency Medicaid to cover their hospital stay. 
  • Two postpartum visits for the mother after the baby is born 
  • Regular check-ups, immunizations and prescriptions for the baby after the baby left the hospital.


Q:

​Who qualifies for CHIP Perinatal?

Any uninsured pregnant woman can apply. If you are not eligible for Medicaid because of your income or immigration status, you may qualify for CHIP Perinatal.


Q:

What is CHIP Perinatal?

CHIP Perinatal provides free prenatal care for the unborn child. Upon delivery, the child will receive most of the health care benefits available under the traditional CHIP program.


CHIP
Q:

How can I get information regarding the Texas Medicaid/ CHIP Vendor Drug Program?

To obtain information regarding the Texas Medicaid/ CHIP Vendor Drug Program, click here.


Q:

​Can a CHIP member have dual insurance coverage?

In order to be deemed eligible for CHIP, a member must not have other healthcare coverage. If it is discovered a CHIP member has dual coverage, please contact the health plan at (210) 358-6300.


Q:

​Are contraceptives a covered benefit for CHIP members?

Contraceptives are not a covered benefit.


Q:

​Are Back to School or Sports Physicals a covered benefit for CHIP?

Back to School and Sports Physicals are value added benefits which became effective August 01, 2008.


Q:

What is the age limit for CHIP members?

The age limit for CHIP members is 0-19 years of age.


HMO
Q:

Where can I locate a copy of a member's prescription formulary?

The Pharmacy Benefits page provides more information for commercial members.


Q:

​ Are members required to have a referral to visit a participating specialist?

A PCP referral may be required for a consultation with a participating network specialist, depending on the physician group. However, the following specialties do not require a referral:

- OB/GYN
- Family Planning
- Behavioral Health
- Vision


STAR Kids/STAR Medicaid
Q:

How can I get information regarding the Texas Medicaid/ CHIP Vendor Drug Program?

To obtain information regarding the Texas Medicaid/ CHIP Vendor Drug Program, click here.


Q:

How can I get information regarding the Texas Medicaid and Healthcare Partnership?

If you would like more information regarding the Texas Medicaid and Partnership, click here.


Q:

Where do I obtain current checkup forms?

Checkup forms may be located on the TMHP website, appendix C of the current Medicaid provider manual contains Texas Health Steps forms.


Q:

Do I need special training or education to perform Texas Health Steps checkups?

Community First Health Plans provides training and education to contracted Texas Health Steps providers, contact your provider relations representative at (210) 358-6190.


Texas Health Steps
Q:

Where can I locate a copy of a member's prescription formulary?

The Pharmacy Benefits page provides more information for UFCP members.


Q:

Are members required to have a referral to visit a participating specialist?

A PCP referral may be required for a consultation with a participating network specialist, depending on the physician group. However, the following specialties do not require a referral:

- OB/GYN
- Family Planning
- Behavioral Health
- Vision


Q:

What is the process for changing PCP?

Members may change their PCP at anytime by contacting Community First Health Plans Member Services Department at (210) 358-6090.


Q:

​Where do I obtain current checkup forms?

Checkup forms may be located on the TMHP website, appendix C of the current Medicaid provider manual contains Texas Health Steps forms.


Q:

What is the difference between Back to School physical and a Texas Health Steps checkup?

A Back to School Physical is allowed once per calendar year or by date of service (every twelve months) and covered for Medicaid members ages (0-19)


Q:

Do I need special training or education to perform Texas Health Steps checkups?

Community First Health Plans provides training and education to contracted Texas Health Steps providers, contact your provider relations representative at (210) 358-6190.


Q:

How do I become a Texas Health Steps provider?

Contact Texas Medicaid Healthcare Partnership (TMHP) at (800) 925-9126 enrollment department


Q:

When performing a Texas Health Steps checkup must I complete all elements and components?

All components listed on the Periodicity Schedule must be completed for the checkup to be considered a compliant Texas Health Steps checkup. If any component can not be completed due to medical contraindications, a follow-up appointment must be completed as soon as possible to perform the "missed" component.


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