Information That Must Be Available on an Annual Basis
As a Member of Community Health Choice, you can ask for and get the following information each year:
- Information about network Providers – at a minimum primary care doctors, specialists, and hospitals in our service area. This information will include names, addresses, telephone numbers, and languages spoken (other than English) for each network provider, plus identification of Providers that are not accepting new patients.
- Any limits on your freedom of choice among network Providers
- Your rights and responsibilities
- Information on complaint, appeal, and fair hearing procedures
- Information about benefits available under the Medicaid program, including amount, duration, and scope of benefits. This is designed to make sure you understand the benefits to which you are entitled
- How you get benefits, including authorization requirements
- How you get benefits, including family planning services, from out-of-network Providers and limits to those benefits.
- How you get after hours and emergency coverage and limits to those kinds of benefits, including:
- What makes up emergency medical conditions, emergency services, and post-stabilization services
- The fact that you do not need prior authorization from your Primary Care Provider for emergency care services
- How to get emergency services, including instructions on how to use the 9-1-1 telephone system or its local equivalent
- The addresses of any places where Providers and hospitals furnish emergency services covered by Medicaid
- A statement saying you have a right to use any hospital or other settings for emergency care
- Post-stabilization rules
- Policy on referrals for specialty care and for other benefits you cannot get through your Primary Care Provider
- Community Health Choice’s practice guidelines
Important Things to Remember
We are here to help you get the most from your health coverage. Here are some important things to remember:
- Read your handbook. If you have any questions, call Member Services toll-free at 1.888.760.2600.
- Read your Rights and Responsibilities as a plan Member in your handbook.
- Find a Primary Care Provider on our online Provider Directory. If you need help finding a provider, call Member Services toll-free at 1.888.760.2600. When you pick your Provider, you must call us so we can assign that Provider to you. You can also create an online account at CommunityHealthChoice.org > Member Login and choose your Primary Care Provider.
- You will receive your Community Health Choice Member ID card within 5-7 business days after you have told us who you chose to be your Primary Care Provider. Review your information on the card. If there are any errors, contact us immediately.
- Call your Primary Care Provider listed on your Member ID card to schedule your first Texas Health Steps checkup:
- As a new Member, you should have your first Texas Health Steps checkup within 90 calendar days after joining Community Health Choice.
- Newborns should be seen by a Primary Care Provider 3-5 days after birth.
- Show your Community Health Choice Member ID card every time you go to the doctor’s office, clinic, hospital or drug store to get your prescription filled.
- If you have special health care needs, we can help! We can enroll you into one of our Care Management Programs or refer you to the Case Management for Children and Pregnant Women Program.
- If you are a Member of a migrant farmworker family, we can help you get all the health care services you need before you travel.
- Always carry your Community Health Choice Member ID card with you.
In addition to these, Community Health Choice believes you have the right and responsibility to:
- A right to receive information about the organization, its services, its practitioners and providers and member rights and responsibilities
- A right to be treated with respect and recognition of your dignity and your right to privacy
- A right to participate with practitioners in making decisions about your health care
- A right to a candid discussion of appropriate or medically necessary treatment options for their conditions, regardless of cost or benefit coverage
- A right to voice complaints or appeals about the organization or the care it provides
- A right to make recommendations regarding the organization’s Member rights and responsibilities policy
- A responsibility to supply information (to the extent possible) that the organization and its practitioners and providers need in order to provide care
- A responsibility to follow plans and instructions for care that you have agreed to with their practitioners
- A responsibility to understand your health problems and participate in developing mutually agreed-upon treatment goals, to the degree possible
You have a right to tell us what you think of the rights and responsibilities offered to you. Tell us what you think at 1.888.760.2600.
New Technology Assessment
We provide for care that is shown to be safe and useful. We review new health care treatments. We review new procedures. The review uses up to date health data. This is called New Technology Assessment. We decide whether to pay for these things. This review means we pay when safety and value is clear. You may ask us to review new technology. The Texas Vendor Drug Program reviews medications.
Utilization Management Decisions
Community follows guidelines to determine what health care services we cover. This is called utilization management. We know how important it is that we make the right decisions for your care. Community follows three principles when we make these decisions:
- Our decisions are based only on whether or not:
- The care and services are appropriate
- It is a covered benefit
- We do not reward doctors or anyone else for denying coverage.
- We do not give incentives to doctors or anyone else to encourage them to make decisions that would mean you would get less care than you need.
- If Community denies your request for services, you can get an independent external review. An independent review is when someone not employed by Community reviews your request for services. This is called a Fair Hearing.
Our Quality Improvement Department helps Community give you the best clinical care and service possible. If you want more information about our Quality Improvement Program, please contact Member Services toll-free at 1.888.760.2600.
If you need information about sexually-transmitted diseases (STDs) or Human Immunodeficiency Virus (HIV), please call Community’s Member Services at 713.295.2294 or toll-free at 1.888.760.2600.