最新糖心Vlog

Call Member Services at 1-888-814-2352 (TTY 7-1-1) or view your Member Handbook.

Hours of operation are Monday - Friday from 8 am to 5 pm. 

If you have health-related questions, call our 24-hour Nurse Line at 1-800-357-3162 for help from a nurse 24 hours a day, 7 days a week.

We have special services for people who have trouble reading, hearing, or seeing, or speak a language other than English or Spanish. If you prefer materials in alternate formats, we will mail you a hardcopy, or you can ask for the handbook in audio, Braille, large print, or another language 鈥� at no cost to you. Just contact us, and we鈥檒l make sure you get it in the format you need.

Please call Member Services at 1-888-814-2352 (TTY 7-1-1) to contact interpreter services.

Once you have chosen 最新糖心Vlog Community Health Plan, 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 PCHP鈥檚 extensive network of family or general practitioners and pediatricians. The selection of a PCP is crucial for immediate access to acute and preventive care.

Find a list of physicians and providers in the 最新糖心Vlog Community Health Plan network. You can also call our Member Services department at 1-888-814-2352 for assistance.

A referral is when your primary care provider (PCP) recommends that you or your child see a specialist for care they cannot provide in their office. Your PCP can help you choose the right specialist and coordinate the next step in your care. If your doctor refers you to an in-network doctor, you do not need to get approval from 最新糖心Vlog Community Health Plan (PCHP) before you visit that doctor. However, referrals to out-of-network doctors; and certain services, treatments, or procedures you may receive from your doctors may require approval. That approval is called prior authorization. Your doctors are responsible for coordinating prior authorizations with PCHP, but if you have any questions, call Member Services at 1-888-814-2352.

The Member Guide you received from CHIP when you enrolled your child includes a tear-out form you can use to track your CHIP expenses. Use this form to keep a record of your copayments so you do not go over your family鈥檚 cost-sharing limit.

You also received a welcome letter that tells you the exact amount you must spend before reaching your cost-sharing limit. When you reach that amount, mail the completed form back to CHIP. CHIP will then notify 最新糖心Vlog Community Health Plan (PCHP), and we will send your child a new Member ID card showing that no copayments are due for the rest of the enrollment period.

If you lose your welcome letter, call PCHP Member Services at 1-888-814-2352. We can tell you your annual cost-sharing limit and help answer any questions.

If you suspect a client (a person who receives benefits) or a provider (e.g., doctor, dentist, counselor, etc.) has committed fraud, waste, or abuse, you have a responsibility and a right to report it.

Fill out our fraud, waste, or abuse form, and submit it to us directly by:

• Mail: 最新糖心Vlog Community Health Plan
  Attn: Special Investigations Unit
  P.O. Box 560307
  Dallas, TX 75356
• Phone: 1-888-209-3841
  Available 24 hours a day, 7 days a week.
• Email: PCHPSIU@phhs.org

For more information, visit our Fraud & Abuse page.

What is a prior authorization?

Under medical and prescription drug plans, certain services and medications may need approval from PCHP before they鈥檙e covered. This approval is called a prior authorization, and your doctor will work with PCHP to get this approval for you.

What types of medications typically need approval?

Those that:

• May be unsafe when combined with other medications
• Have lower-cost, equally effective alternatives available
• Should only be used for certain health conditions
• Are often misused or abused
• Are often used for cosmetic purposes

Medications that require approval will only be covered by your plan if your doctor requests and receives approval from PCHP.

What types of services typically need approval?

Your doctor and PCHP can tell you if the services you need will require prior authorization. You member handbook is also a good resource and lists limitations and exclusions for your health plan. Generally, these services may require prior authorization:

• Durable medical equipment
• Home health
• Private duty nursing
• Rehabilitation
• Surgery
• Therapy

Refer to your member handbook or call Member Services if you have questions about services requiring prior authorization.

What鈥檚 the difference between prior authorization and pre-authorization?

None; these terms mean the same thing and are used interchangeably. However, most insurance companies will use the term 鈥減rior authorization鈥� instead of 鈥減re-authorization.鈥�

How does the prior authorization process work?

Prior authorizations are handled by your doctor鈥檚 office and PCHP. We will contact you with the results to let you know if your medications or services have been approved or denied, or if we need more information.

If you are unhappy with your prior authorization decision, you or your doctor can ask for a review of the decision. In the case of denials for prescription drugs, your doctor may choose to prescribe a different but equally effective medication. In some instances, PCHP may recommend you try an alternative medication that鈥檚 less costly, but equally effective, before the medication your doctor originally prescribed can be approved.

Learn more here.