Member FAQs
Frequently Asked Questions
Who makes up the Member Advisory Group?
Our current membership on the Member Advisory Group (MEAB) is made up of members and parents, who have children as members of this health plan, they work in social services, schools, and community agencies and provide valuable insight to the health plan. Several of them have been with CFHP for many years, they live in various parts of the city. They provide a vehicle for obtaining insight into the perceptions and expectations of health plan consumers, and to enable the health plan to tailor policies and operations to best meet the needs of the membership. Since members are key in providing input on issues related to health plan education, health plan services, and to serve in designated committees within Community First Health Plan, MEAB is an excellent way of facilitating these endeavors. If you are interested in learning about how you can participate, call Member Services at 1-800-434-2347.
STAR Kids: 1-855-607-7827
STAR Kids Member Advisory Committee
Community First Health Plans is seeking STAR Kids members or their representatives to participate on the new STAR Kids Member Advisory Committee (SK MAC). The Committee is dedicated to provide an opportunity for STAR Kids families to share insights about their perceptions and expectations of the health plan.
The goal of the new Advisory Committee is to provide recommendations and/or input to allow the health plan to make any changes to the operations and/or educational opportunities that best meet the needs of STAR Kid membership. For questions or to express your interest in participating in the STAR Kids Member Advisory Committee please contact STAR Kids at:
210-358-6403 or 1-855-607-7827.
How can I receive member materials in a different format other that print?
Provider Directories, Member Handbooks, and CFHP Member Newsletters are available in print, free of charge, and mailed within 5 days, by calling 1-800-434-2347 or by making a request through your secure Member Portal.
If you need any member materials in a different format, for example large print, Braille, audio, etc, please contact Member Services at 1-800-434-2347.
What is the member portal?
To access your secure Member Portal, CLICK HERE to register. This is a secure website where you can request an ID card, ask to change your PCP, file a complaint, or ask a question. If you are more comfortable talking to a Member Services Advocate you can call us toll-free at 1-800-434-2347. We are here to help you!
Who is my Primary Care Provider (PCP)?
Your Primary Care Provider (PCP) is your own doctor or clinic who will provide or arrange your medical care. You can search for a PCP or any specialist within the Community First network on this website using the “Find a Provider” link.
How do I change my Primary Care Provider (PCP)?
You can request to change your PCP through the secure Member Portal, or you can call member services at 1-800-434-2347 and a representative can help you designate a new PCP.
What is Community First's Service Area?
Community First’s service area includes all of Atascosa, Bandera, Bexar, Comal, Guadalupe, Kendall, Medina and Wilson counties.
What services are available when I am outside Community First's service area?
The only services covered outside Community First’s service area are emergency room visits (E.R.). If you want to receive services outside the service area, with the exception of E.R. visits, a prior authorization will be required before the visit. Also, if medically necessary covered services are not available through Community First’s participating providers, Community First may allow you to see non-participating provider with a prior authorization request from the provider of your choice.
What do I do if I am a new member?
Once you have chosen Community First, 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 Community First’s extensive network of family or general practitioners and pediatricians. The selection of a PCP is crucial for immediate access to acute and preventive care. Click here for a list of physicians and providers in the Community First network. You can also call our Member Services department at 1-800-434-2347 for assistance.
When can I receive/ replace my Member ID card?
CFHP makes every effort to provide new Members with ID cards as quickly as possible once enrollment information is transmitted. However, during the time of enrollment processing, Members and providers may verify eligibility through CFHP’s secure portal. Member information is updated daily.
If you need to request a replacement or additional ID card, you may do so through our secure web portal. You may also call Member Services at (210) 227-2347 or toll-free at 1-800-434-2347.
Is a referral or authorization required to see a specialist?
Community First does not require a referral to see a specialist. Some specialists may require a referral from your PCP in order to see you. Additionally, some services require a pre-authorization from Community First before you receive services. Your PCP will take care of this request for you. You can call Member Services to find out if a certain service requires authorization.
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.
What emergency, after hours, and urgent care services are available?
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
- Serious disfigurement
- 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.
What do I do if I get a bill?
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. You can also submit an inquiry through the secure member portal for assistance with your bill.
How can I contact interpreter services?
Please call member services at (210) 227-2347 to contact interpreter services.
What is the name of the pharmacy vendor (for prescription benefits)?
Your health plan includes a 3-tier prescription drug benefit, which is administered by Community First and our Pharmacy Benefit Manager (PBM), Navitus Health Solutions. Please click here for more information about your pharmacy benefits.
How do I file a complaint?
If you have a complaint, please call us toll-free at:
STAR Medicaid: 1-800-434-2347, option 3 or 210-358-6060
STAR KIDS: 1-855-607-7827 or 210-358-6403
You may also send us a written complaint request to:
Community First Health Plans
12238 Silicon Drive, Suite 100
San Antonio, TX 78249
Attention: Member Services Resolution Unit
A Community First Member Services Representative can help you file a complaint. You may also send us a secure request on our website through the Member Portal. We will let you know we received your complaint, by mail, within five days and send you a resolution letter within 30 days. If you are not happy with the outcome, you may file an appeal.
File a complaint:
If you get benefits through Medicaid’s STAR program, call your medical plan first. If you don’t get the help you need there, you should do one of the following:
a. Call Medicaid Managed Care Helpline at 1-866-566-8989 (toll free).
b. Online: Online Submission Form (only works in Internet Explorer)
c. Mail: Texas Health and Human Services Commission
Office of the Ombudsman, MC H-700
P.O. Box 13247
Austin, TX 78711-3247
d. Fax: 1-888-780-8099 (Toll-Free)
STAR Kids: 1-855-607-7827
STAR Kids Member Advisory Committee
Community First Health Plans is seeking STAR Kids members or their representatives to participate on the new STAR Kids Member Advisory Committee (SK MAC). The Committee is dedicated to provide an opportunity for STAR Kids families to share insights about their perceptions and expectations of the health plan.
The goal of the new Advisory Committee is to provide recommendations and/or input to allow the health plan to make any changes to the operations and/or educational opportunities that best meet the needs of STAR Kid membership. For questions or to express your interest in participating in the STAR Kids Member Advisory Committee please contact STAR Kids at:
210-358-6403 or 1-855-607-7827.
How can I choose a Primary Care Provider (PCP)?
You can go to Find a Provider page and select your plan to choose a PCP. After your selection, you can update your PCP through your secure Member Portal or by calling member services at 1-800-434-2347.
Note: Please remember to have the name of your new PCP accessible when contacting member services.
For any dental questions, please contact your dental plan:
DentaQuest – 1-800-516-0165
MCNA – 1-855-691-6262
If you need any member materials in a different format, for example large print, Braille, audio, etc, please contact Member Services at 1-800-434-2347.
What is the member portal?
To access your secure Member Portal, click on the Member Login link to register. This is a secure website where you can request an ID card, ask to change your PCP, file a complaint, or ask a question. If you are more comfortable talking to a Member Services Advocate you can call us toll-free at 1-800-434-2347. We are here to help you!
How can I get a breast pump?
Breast pumps are a covered benefit, which covers a manual or non- hospital grade electric breast pump. In order to get a breast pump, you will have to get a prescription from your physician and take it to a participating medical supply provider. If you need help finding a participating medical supply provider, click here.
What extra benefits do Community First Members Receive?
As a Community First Member, you have access to extra benefits also known as Value Added Services. You can find a list of these benefits in your Member Handbook and on our website.
Call us at 1-800-434-2347 (STAR) or 1-855-607-7828 (STAR Kids) to learn more about these and other benefits.
What should I do if I want to file an appeal?
What can I do if my doctor asks for a service or medicine for me that’s covered but Community First Health Plans denies it or limits it?
Community First might deny a health care service or medicine if it is not medically necessary. A medicine can also be denied:
- If the medicine does not work better than other medicines on the Community First Preferred Drug List
- If there is another medicine that is similar that you must try first that you have not used before. If you disagree with the denial you can ask for an appeal.
How will I find out if services are denied?
You will receive a letter telling you about this. You will also get an appeal form.
When does a Member have the right to ask for an appeal?
You can appeal if you are not happy with the decision. You may also ask for an appeal if Community First denied payment of services in whole or part. Just call: STAR Medicaid: 1-800-434-2347 STAR Kids: 1-855-607-7827 or send us a written appeal request:
Community First Health Plans
12238 Silicon Drive Ste.100
San Antonio, TX 78249
Attention: Resolution Department
We will send you an appeal form to fill out and send back to Community First.
Can someone from Community First help me file an appeal?
Yes, we can help you file an appeal. If you call to request an appeal, we will send you an appeal form to fill out and send back to Community First. We must receive a signed, written appeal form from you to begin processing your appeal, unless you are requesting an expedited appeal.
What are the timeframes for the appeal process?
A letter will be mailed to you within 5 days to tell you we received your appeal. We will mail you our decision within 30 days. You have the right to ask for an extension up to 14 days. If Community First needs more information, we might ask for an extension. If we need an extension, we will tell you in writing. We will tell you the reason for the delay and how this will help you. You have the right to keep getting any current medical services Community First already approved while we process your appeal if you file your appeal on or before:
- 10 days from the date you received our decision letter or
- The date our decision letter says your medical services will be reduced or end.
What if I am not happy with the answer to my appeal?
You can request an External Medical Review and State Fair Hearing no later than 120 days after the date Community First Health Plans mails you the appeal decision notice. You also have the option to request only a State Fair Hearing Review no later than 120 days after Community First Health Plans mails you the appeal decision notice.
How can I request an External Medical Review?
If you disagree with the health plan’s internal appeal decision, you have the right to ask for an External Medical Review. An External Medical Review is an optional, extra step the Member can take to get the case reviewed before the State Fair Hearing occurs.
To request an External Medical Review:
– Fill out the State Fair Hearing and External Medial Review Request Form mailed to you and mail or fax it back to us using the address or fax number at the top of the form.
– Call us at (210) 227-2347 or toll free 1-800-434-2347
– Email us at qmappeals@cfhp.com; or
– Go in-person to a local HHSC office
You must ask for the External Medical Review within 120 days of the date the health plan mails the letter with the internal appeal decision. If you do not ask for the External Medical Review within 120 days, you may lose your right to an External Medical Review.
You can learn more about External Medical Reviews by reading your Member Handbook or by visiting our External Medical Review and State Fair Hearing page.
What Is A State Fair Hearing?
If you disagree with the health plan’s internal appeal decision, you have the right to ask for a State Fair Hearing. A State Fair Hearing is when the Texas Health and Human Services Commission (HHSC) directly reviews our decisions with your medical care.
To request a State Fair Hearing:
– Fill out the State Fair Hearing and External Medial Review Request Form mailed to you and mail or fax it back to us using the address or fax number at the top of the form.
– Call us at (210) 227-2347 or toll free 1-800-434-2347
– Email us at qmappeals@cfhp.com; or
– Go in-person to a local HHSC office
You must ask for a State Fair Hearing within 120 days of the date the health plan mails the letter with the internal appeal decision. If you do not ask for a State Fair Hearing within 120 days, you may lose your right to a State Fair Hearing.
You can learn more about State Fair Hearing by reading your Member Handbook or by visiting our External Medical Review and State Fair Hearing page.
Who do I contact if I have questions regarding my vision benefits?
Please contact member services regarding your vision eligibility and benefits at 210-358-6300, or follow this link if you are looking for your provider contracted with your vision plan.
Who do I contact if I have questions about my dental benefits?
Please contact your dental plan:
DentaQuest – 1-800-516-0165
MCNA – 1-855-691-6262
If you have any additional questions regarding your eligibility, please contact member services at (210) 227- 2347.
What is a prenatal care provider?
Your prenatal care network provider is an OB/GYN of your choice. Please keep in mind that this provider has to be contractedwith Community First for services to be covered under the health plan. You do not need a referral to select an OB/GYN.
What extra benefits does a pregnant Member receive?
CHIP Perinatal members and pregnant STAR and STAR Kids Members have access to extra benefits called Value-Added Services. You can find a list of these benefits in your Member Handbook and on our website.
STAR/CHIP Value-Added Services
STAR Kids Value-Added Services
CHIP Perinatal Value-Added Services
Community First also offers Members an opportunity to join Healthy Expectations, a maternity program for expecting mothers. Healthy Expectations provides prenatal education and special incentives, including gift cards and baby items, for qualifying Members. You can learn more about Healthy Expectations here.
Call us at 1-800-434-2347 (STAR/CHIP) or 1-855-607-7827 (STAR Kids) to learn more about these and other benefits.
MEMBER HANDBOOKS