If your primary care provider thinks you need to see a special doctor, you will be sent to a specialist. Your doctor will take care of the paperwork and can help you make the appointment. Some services require an authorization from Member Services before you get services . Your doctor will take care of this request for you. You can call Member Services to find out if a certain service requires authorization.
Some services do not require a referral:
Behavioral health services
Vision exams from an optometrist
Texas Health Steps checkups
Family planning services
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.
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:
Placing the patient's health in serious jeopardy
Serious impairment to bodily functions
Serious dysfunction of any bodily organ or part
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.
Call Member Services at (210) 227-2347 or toll-free at 1-800-434-2347 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 for amounts not paid by the enrollee’s health benefit plan (Texas Insurance Code §1456.001,003).
If you have a complaint, please call us toll-free at 1-800-434-2347 or send us a secure request through our secure member portal to tell us about your problem. A Community First Member Services Representative can help you file a complaint. Most of the time, we can help you right away or at the most within a few days.
STAR/Medicaid Members: Once you have gone through the Community First Health Plans complaint process, you can complain to the Health and Human Services Commission (HHSC) by calling toll-free 1-866-566-8989. If you would like to make your complaint in writing, please send it to the following address:
Texas Health and Human Services Commission Health Plan Operations - H-320 P.O. Box 85200 Austin, TX 78708-5200 ATTN: Resolution Services Email: HPM_Complaints@hhsc.state.tx.us
CHIP/CHIP Perinatal/Commercial HMO Members: You can file a complaint with the Texas Department of Insurance (TDI) at any time. You can contact TDI at:
Call Member Services. A Member Service Representative can help you pick a new primary care provider. You can also request to change your primary care provider by submitting a secure request through our secure member portal.