Provider FAQs

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 210-358-6294.

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

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.

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.

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.

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.

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

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.

For more information about the Texas Medicaid and HealthcarePartnership, please visit https://www.tmhp.com/.

You can find a copy of Member Rights and Responsibilities in our Member Knowledge Base.

Checkup forms can be located on the TMHP website.

Appendix C of the current Texas Medicaid Provider Procedures Manual contains Texas Health Steps forms.

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.

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

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

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.

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.

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.

Member Rights & Responsibilities can be found on our Member Resources page.

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) 358-6294.

To learn more about the Texas Medicaid/CHIP Vendor Drug Program, please visit https://www.txvendordrug.com/.

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.

Sports/school physicals are a no-cost Value Added Services for CHIP Members. (One physical each year for Members ages 18 and younger.)

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.

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