Provider FAQs
How do I apply to become a Community First network Provider?
If you would like to apply to become a network Provider with Community First, please fill out our Letter of Interest.
How can I contact Provider Relations?
If you would like to contact Provider Relations, please call the Provider Services Hotline at (210) 358-6294 or email ProviderRelations@cfhp.com. You can also reach out to your Provider Relations Representative directly.
WHO FORMS THE PROVIDER OFFICE STAFF ADVISORY COMMITTEE?
The provider office staff advisory committee (POSAC) consists of PCP, specialty, and other provider representatives to discuss and collaborate on issues that have an impact on our Providers and Members. To find out more information about joining the Community First POSAC, please contact Network Management at 210-358-6030.
How can I file a complaint or an appeal?
To file a Provider complaint or appeal, please use the following contact information:
Phone: (210) 358-6294 or (210) 358-6030
Email: nmcfhp@cfhp.com
Fax: (210) 358-6199
Medicaid managed care providers can also submit complaints and inquiries directly to HHSC Managed Care Compliance and Operations (MCCO) via:
Email: HPM_complaints@hhsc.state.tx.us
Fax: (512) 491-1958
Mail:
Health and Human Services Commission Medicaid/CHIP
Managed Care Compliance and Operations
P.O. Box 149030 MC-0210
Austin, TX78714-9030
What is Cultural Competency?
Community First Health Plans maintains a comprehensive Cultural Competency plan, which includes education and outreach activities that are culturally sensitive, meet the language and literacy needs of the targeted population, and will work to minimize communication and physical access barriers. The purpose is to effectively provide, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs. The manner in which services are provided will recognize value, affirm and respect the worth of the individual and protect and preserve personal dignity.
Community First Provider Manuals include information regarding Provider access to linguistic and interpreter services available through Community First and information regarding bilingual health plan and Member materials available for Provider use.
How do I get access to the Provider Portal?
Providers must submit a completed Provider Portal agreement. Providers will then be assigned a user name and password. Contact your Provider Relations Representative to obtain a Provider Portal agreement.
Note: Community First has unveiled a brand new Provider Portal with increased functionality and a better user experience for our valued Providers. Please check our registration page for more information.
Who can I contact for help with the Provider Portal?
New Community First Providers are given a formal training and tour of our secure Provider Portal. Contact your Provider Relations Representative or call the Provider Services Hotline at (210) 353-6030 for any issues, concerns, or questions.
Note: Community First will soon be unveiling a brand new Provider Portal with increased functionality and a better user experience for our valued Providers. Please check your email for more information.
Can I request online authorizations/referrals?
You may request online authorizations/referrals and check the status of your request through the AcuExchange System. You must first request access from our Network Management Department by calling (210) 358-6030.
Can I submit claims via the Provider Portal?
Online claims submissions are now available through the Provider Portal under Claim MD. You may also appeal a claim through the secure Provider Portal.
If there are further questions about a claim and/or an appeal, use the contact information listed below:
- Phone: 210-358-6030
- Fax: 210-358-6199
- Email: ProviderRelations@cfhp.com
What functions are available on the Provider Portal?
The following functions are available on the Provider Portal:
- Verify Member’s eligibility/status
- Claim status inquiry
- EOP inquiry
- Provider panel rosters
- Online Provider search directory
- Texas Health Steps exams (new, due, overdue)
Note: Community First will soon be unveiling a brand new Provider Portal with increased functionality and a better user experience for our valued Providers. Please check your email for more information.
Where can I get more information about the Texas Medicaid and Healthcare Partnership?
For more information about the Texas Medicaid and HealthcarePartnership, please visit https://www.tmhp.com/.
Where can I obtain a copy of Member Rights and Responsibilities?
You can find a copy of Member Rights and Responsibilities in our Member Knowledge Base.
Where can I obtain current checkup forms?
Checkup forms can be located on the TMHP website.
Appendix C of the current Texas Medicaid Provider Procedures Manual contains Texas Health Steps forms.
ARE MEMBERS ASSIGNED A PRIMARY CARE PROVIDER (PCP)?
Depending on the Member’s health plan, the Member may be required to select a PCP upon enrollment.
STAR and CHIP/CHIP Perinate Newborn Members: STAR and CHIP Members are required to select a PCP or one will be selected for them.
STAR Kids Members: For STAR Kids and STAR+PLUS Members who are covered by Medicare, no PCP will be assigned.
WHERE CAN I FIND OUT MORE ABOUT CASE MANAGEMENT SERVICES FOR CHILDREN AND PREGNANT WOMEN (CPW)?
Case Management for Children and Pregnant Women is a Medicaid benefit that provides health-related case management services to children birth through 20 years of age with a health condition and to high-risk pregnant women of any age. Case managers help clients gain access to needed medical, social, educational, and other services.
Refer to this list of CPW FAQs for provider qualifications and Medicaid enrollment.
Case Management for Children and Pregnant Women – Provider FAQs
Where can I locate a copy of a member's prescription formulary?
Visit our Pharmacy Benefits page for pharmacy resources, including prescription formularies.
Are members required to have a referral to visit a participating specialist?
A PCP referral may be required for a consultation with a participating network specialist, depending on the physician group. However, the following specialties do not require a referral:
– OB/GYN services
– Family planning services
– Behavioral health services
– Vision
What is the process for changing primary care providers?
Members may change their PCP at any time by contacting Member Services or by logging into the Member Portal. PCP changes are effective immediately.
What is the difference between Back-to-School physicals and a Texas Health Steps checkups?
Back-to-school/sports physicals are allowed once per calendar year or by date of service (every 12 months) and covered for Medicaid Members ages 0 through 19.
Texas Health Steps checkups are on a periodicity schedule and include:
• Free regular medical checkups starting at birth.
• Free dental checkups starting at six months of age.
• A case manager who can find out what services a child needs and where to get these services.
Do I need special training or education to perform Texas Health Steps checkups?
Community First Health Plans provides training and education to contracted Texas Health Steps Providers. Contact your Provider Representative or call our Provider Services Hotline at 210-353-6030 for more information.
How do I become a Texas Health Steps Provider?
Contact Texas Medicaid Healthcare Partnership (TMHP) at 1-800-925-9126 and select Option 3. You can also visit the TMHP Provider Enrollment page for more information.
When performing a Texas Health Steps checkup, Are all components required?
All components listed on the Texas Health Steps Medical Checkup Periodicity Schedule for Infants, Children, and Adolescents must be completed for the checkup to be considered a compliant Texas Health Steps checkup. If any component can not be completed due to medical contraindications, a follow-up appointment must be completed as soon as possible to perform the “missed” component.
Where can I find a copy of Member Rights & Responsibilities?
Member Rights & Responsibilities can be found on our Member Resources page.
Can a CHIP Member have Dual Insurance Coverage?
In order to be deemed eligible for CHIP, a Member must not have other healthcare coverage. If it is discovered a CHIP Member has dual coverage, please contact the Provider Services Hotline at (210) 358-6030.
Where can I get information about the Texas Medicaid/CHIP Drug Vendor Program?
To learn more about the Texas Medicaid/CHIP Vendor Drug Program, please visit https://www.txvendordrug.com/.
ARE CONTRACEPTIVES A COVERED BENEFIT FOR CHIP MEMBERS?
Contraceptive medications prescribed only for the purpose of primary and preventive reproductive health care (i.e. prescribed for family planning) are not a covered service for CHIP Members.
ARE SCHOOL/SPORTS PHYSICALS A COVERED BENEFIT FOR CHIP?
Sports/school physicals are a no-cost Value Added Services for CHIP Members. (One physical each year for Members ages 18 and younger.)
What is the age limit for CHIP Members?
To get Medicaid or CHIP, a child must be age 18 and younger (in some cases children with disabilities age 19 and 20 can get Medicaid). They must also be a Texas resident and a U.S. citizen or qualified non-citizen.
How Can I Get Information About Credentialing and Re-credentialing?
All applicants for participation undergo a careful review of their qualifications, including education, training, licensure status, board certification, hospital privileges, and work and malpractice history. Providers who meet the criteria and standards of Community First are presented to the Credentials Committee for final approval of their credentials.
Re-credentialing is performed at least every three years. In addition to the verification of current license, DEA, malpractice insurance, National Practitioner Data Bank query, and current hospital privileges, the process may also include:
• Member survey results
• Complaints and Grievances
• Utilization data
• Compliance of Community First policies & procedures
• An office site review and evaluation
• A medical record audit
Can’t find the answer you need?
Please call our Provider Services Hotline at 210-358-6030, Monday through Friday, 8:30 a.m. to 5 p.m., or fill out the form below to have a Provider Representative contact you.
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