Insurance Information

Insurance Information

How do I find a Primary Care Provider or clinic?

Use our online Provider Search to find a Primary Care Provider or clinic. It is updated every weekday, excluding holidays. You also can search through our printed directories, which are updated quarterly.

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Ready to Apply for CHIP? Applying is easy. 

What is a Referral?

A referral is a consultation for evaluation and/or treatment of a patient requested by one doctor to another doctor. Community Health Choice will not pay the cost of non-emergency hospital care or medical equipment unless your Primary Care Provider gives you a referral.

These CHIP & CHIP-P services do not need a referral from a Primary Care Provider

  • Emergency care for CHIP and CHIP Perinatal Newborn Members
  • Emergency care for CHIP Perinatal Members: Emergency services and/or emergency medical care are covered services only if it is labor resulting in delivery of your baby. If your emergency care is not related to labor with the birth of your child, you will have to apply for Emergency Medicaid or pay for the services yourself.
  • OB/GYN care
  • Prenatal care: You may receive prenatal care without a referral. Your CHIP Perinatal Provider must request referral authorization for some tests and procedures and must notify us of pregnancy care visits.
  • Behavioral (mental) health services or drug and alcohol treatment

Health Care Definitions

A request for your managed care organization to review a denial or a grievance again.

A grievance that you communicate to your health insurer or plan.

A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.

Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches, or blood testing strips for diabetics.

An illness, injury, symptom, or condition so serious that a reasonable person would seek care right away to avoid harm.

Ground or air ambulance services for an emergency medical condition.

Emergency services you get in an emergency room.

Evaluation of an emergency medical condition and treatment to keep the condition from getting worse.

Health care services that your health insurance or plan doesn’t pay for or cover.

A complaint to your health insurer or plan.

Health care services such as physical or occupational therapy that help a person keep, learn, or improve skills and functioning for daily living.

A contract that requires your health insurer to pay your covered health care costs in exchange for a premium.

Health care services a person receives in a home.

Services to provide comfort and support for persons in the last stages of a terminal illness and their families.

Care in a hospital that requires admission as an inpatient and usually requires an overnight stay.

Health care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.

The facilities, providers, and suppliers your health insurer or plan has contracted with to provide health care services.

A provider who doesn’t have a contract with your health insurer or plan to provide covered services to you. It may be more difficult to obtain authorization from your health insurer or plan to obtain services from a non-participating provider, instead of a participating provider. In limited cases such as there are no other providers, your health insurer can contract to pay a non-participating provider.

A Provider who has a contract with your health insurer or plan to provide covered services to you.

Health care services a licensed medical physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) provides or coordinates.

A benefit, like Medicaid, to pay for your health care services.

A decision by your health insurer or plan before you receive it that a health care service, treatment plan, prescription drug, or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval, or pre-certification. Preauthorization isn’t a promise your health insurance or plan will cover the cost.

The amount that must be paid for your health insurance or plan.

Health insurance or plan that helps pay for prescription drugs and medications.

Drugs and medications that by-law require a prescription.

A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services for a patient.

A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist, or physician assistant, as allowed under state law, who provides, coordinates, or helps a patient access a range of health care services.

A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), health care professional, or health care facility licensed, certified, or accredited as required by state law.

Health care services such as physical or occupational therapy that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled.

Services from licensed nurses in your own home or in a nursing home.

A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions.

Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.

Advance Directives & Second Opinions

What are advance directives?
Advance directives are legal papers that allow you to say if you would accept or refuse medical treatment if you become too ill to speak for yourself. These papers can help your family decide what to do for you to relieve them of the stress of making the decision for you. It also helps the doctor care for you according to your wishes.

How do I get an advance directive?
Ask your doctor for the form(s) for advance directives. CHIP/STAR (Medicaid) Members, call our Member Services toll-free at 1.888.760.2600 if you need more information.

How can I ask for a second opinion?
Please call our Member Services if you want a second opinion. You can get a second opinion from a network Provider or an out-of-network provider if a network Provider is not available. You may want to ask for a second opinion if:

  1. You received a diagnosis or instructions from your Provider that you don’t feel are correct or complete
  2. Your Provider says you need surgery
  3. You have done what the doctor asked, but you are not getting better

When you go for your visit, tell the doctor you are there for a second opinion.

CHIP Member Services
Local: 713.295.2294 | Toll-Free: 1.888.760.2600

Monday through Friday (excluding State-approved holidays) 8:00 a.m. to 6:00 p.m

General Information
Local: 713.295.2222 | Toll-Free: 1.877.635.6736

Monday through Friday (excluding State-approved holidays) 8:00 a.m. to 6:00 p.m.

Providers Hotline
Local: 713.295.2295
Monday through Friday (excluding State-approved holidays) 8:00 a.m. to 5:00 p.m

Additional Contact Numbers

CHIP Member Services
Local: 713.295.2294 | Toll-Free: 1.888.760.2600

Monday through Friday (excluding State-approved holidays) 8:00 a.m. to 6:00 p.m

General Information
Local: 713.295.2222 | Toll-Free: 1.877.635.6736

Monday through Friday (excluding State-approved holidays) 8:00 a.m. to 6:00 p.m.

Providers Hotline
Local: 713.295.2295
Monday through Friday (excluding State-approved holidays) 8:00 a.m. to 5:00 p.m

Additional Contact Numbers

Why Choose Community?

As a local nonprofit health plan, Community Health Choice gives you plenty of reasons to join our Community. From the benefits and special programs we offer to the way our Member Services team helps you make the most of them, Community is always working life forward for you and your family.

“I always tell people to choose Community Health Choice. I tell them it’s the best health insurance they will ever be with.”

– Chandolyn
Member of Community Health Choice