About Your Care

Authorizations & Referrals

Understanding how your health plan works and where to get care is important. To help you, here are some key terms and details about prior authorization and referrals.

Your primary care physician (PCP) plays a vital role in coordinating your healthcare services, including getting necessary referrals or prior authorizations. With a PCP, you can manage most of your health needs or be referred to a specialist when needed.

You can choose your PCP when you sign up, and you have the flexibility to change your PCP anytime through CHPConnect or by calling CHP Member Services at 850-383-3311.

A specialist is a type of doctor or healthcare professional who has additional training in a specific area of medicine. If you have a specific health issue and need to see a specialist, you should first discuss it with your primary care doctor (PCP).

Some specialists may require a referral, but having a talk with your doctor can help you save time and money while possibly speeding up the process of getting an appointment. If necessary, your doctor will refer you to the right specialist.

Whether you are seeing a primary care provider, a specialist, or a facility, it's important to use CHP network providers for non-emergency medical services or supplies when using your health insurance. This can help you avoid unexpected costs.

Referrals happen when your PCP directs you to another healthcare expert for more specialized treatment. Your doctor or specialist can tell you if a referral is needed and assist you in getting prior authorization if it's necessary. Often, referrals do not require a prior authorization number.

If you or your primary care physician (PCP) feel you need specialized healthcare that they cannot provide, your PCP will help refer you to the right specialist or facility. To start this process, contact your PCP, either by phone or by making an appointment to discuss your need for a specialist. Keep in mind that some specialists and facilities might not need a referral. Your PCP can help determine if a referral is needed. If it is, they will give you a referral form or send it directly to the right specialist or facility.

At times, you may need approval before receiving certain medical services, this is known as prior authorization. This process requires either your doctor/provider or you to get approval from Capital Health Plan before receiving specific items and services. If the specific item or service is a covered benefit in your plan (refer to your member handbook for specific details), CHP reviews the request and your benefits using criteria based on approved clinical evidence.

CHP uses written criteria based on sound clinical evidence to evaluate the medical appropriateness of health care services. These criteria are objective and based on current clinical and medical evidence and applied with consideration of individual needs and characteristics (e.g., age, comorbidities, prior treatment, and complications), and the availability of services within the local delivery system.
All requests for prior authorization are processed and a determination is communicated within 15 calendar days of receipt of all necessary information, or sooner if your health is in serious jeopardy or if your pain cannot be adequately controlled while a decision is being made; or if your life, health, or ability to regain maximum function is in serious jeopardy.
If prior authorization is needed for a service, consult your PCP, the ordering doctor, or Member Services. Your PCP will manage permissions (prior authorizations) for medical services and prescription drugs. However, it is also your responsibility to ensure that the authorization is in place before receiving the item or service

You can review your Summary of Benefits and Coverage by scanning the QR code on the back of your CHP card or by logging into CHPConnect. After logging into CHPConnect, select "Benefits and Eligibility" from the left menu to view your Summary of Benefits and Member Handbook. You can also use the transparency tool on the left side menu of CHPConnect to help estimate your plan costs.

For questions about referrals or prior authorizations, to request a paper copy of your Summary of Benefits and Coverage, or to talk to a representative, please call member services at 850-383-3311.

Case Management Program

The Capital Health Plan (CHP) Case Management Program is a service offered to all CHP members. Our case managers can offer assistance to members who have experienced a critical incident or have multiple complex conditions and need help navigating their care.

Participation in case management services is voluntary and members can discontinue participation in the Case Management Program at any time. Members are encouraged to work closely with their primary care physician in determining if these services are appropriate in their individual circumstance.

Members or caregivers may also self-refer by contacting Capital Health Plan Member Services. The Case Management team evaluates each referral to determine whether the member is appropriate for inclusion in the program.

Preventive Health Guidelines

Capital Health Plan provides access to recommendations for screening tests, counseling, and immunizations to help prevent illness.

The topics in the guidelines are updated as new research becomes available. U.S. Preventative Services owns and regularly updates a research database that makes it simple to browse by topic and explore details related to each one.

The USPSTF, an independent, non-governmental panel of experts in prevention and primary care, was convened by the Public Health Service to rigorously evaluate clinical research in order to assess the merits of preventive measures. Their recommendations are given a "grade" according to how strongly they are supported by scientific evidence.

Grade A and Grade B services are recommended.
Grade C services are not routinely recommended, but may be appropriate for some people.
Grade D services are NOT recommended because possible harms are deemed to outweigh benefits.

Do keep in mind that these are recommendations for care for people who do not have symptoms of a particular health problem. For example, a guideline for mammography screening would not apply to a woman with breast-related symptoms. Any decisions related to tests and care for you are made in consultation with your primary care physician.

Patient Safety Information

Health care, like any human endeavor, is not immune to mistakes. In fact, as medicine advances—as treatments become more various and sophisticated—care necessarily entails additional possibility for error. Patient safety is a continual concern at Capital Health Plan. One important method we use for safeguarding members is education. How can you help ensure that your care is safe and effective?

Steps for Safer Health Care: What You Can Do

Medications. Make sure both your doctor and pharmacist know all of the medicines that you take, including over-the-counter medications (aspirin, etc.), vitamins, and supplements. Tell them of any drug allergies. Ask your doctor to spell out the name of a prescribed drug and specify the dose. Write this down, so that you can check it against the label on the pharmacy bottle. Either from your doctor or the pharmacist, find out exactly what the drug is for, how to take it (empty or full stomach; time of day), what to avoid while taking it (foods, beverages, or activities), and possible side effects. Read any written information provided about the medicine.

Tests. Find out the results of any test or diagnostic procedure. When tests are ordered or done (even routine tests) ask when and how you will get the results. If the results are late, call your doctor's office to inquire. When you have results, ask what they mean for your care.

Physician-Patient Communication. You should feel comfortable talking with your doctor about your health and treatment. If you have any questions or concerns, express them. Don't hesitate to ask for a simpler explanation or to take notes. You may want a family member or a friend to accompany you, especially to understand a serious condition.

Surgery. Be sure you understand what will happen before and after any surgery. Ask the surgeon what he or she will be doing, how long it will take, and what recovery will be like. If the surgery requires hospitalization, ask whether the surgeon or another physician will take charge of your care after the procedure. Before the procedure, clearly specify to the anesthesiologist or nurse any drug allergies or bad reactions to anesthesia.

The web links below provide important consumer health and patient safety information.

Understanding Quality

From the local to the national level, Capital Health Plan has a reputation for the quality of care and service. We consistently earn:

Excellent accreditation ratings
Industry-leading member satisfaction
Low rates of voluntary disenrollment

Capital Health Plan's Quality Improvement Program ensures that we consistently provide health care services that are:

SAFE: Ensuring that health care services provided for members do not cause harm
EFFECTIVE: Providing services based on scientific knowledge to all who could benefit and not providing unnecessary care to those who don’t
PATIENT-CENTERED: Offering care that is respectful of and responsive to individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions
TIMELY: Reducing delays for both those who receive and those who provide care, and providing care when and where it’s likely to be most effective
EFFICIENT: Providing care that minimizes the waste of equipment, supplies, and time
EQUITABLE: Providing a consistent level of care for all members

Improving Services for Members

Our quality improvement (QI) efforts help improve the health and satisfaction of our members. Click on the links below to review a copy of our current QI Program Description and Workplan, and an evaluation of the status of our QI activities. If you would like additional information, or need a copy of these documents mailed to you, contact our Capital Health Plan Member Services.

Accreditation and Quality Report Cards

The National Committee for Quality Assurance (NCQA) is an independent, not-for-profit organization dedicated to assessing and reporting on the quality of health plans. CHP has maintained an accreditation rating of “Excellent”—the highest accreditation rating possible from NCQA—since 2001. Click on the NCQA website below to request a report card for CHP. The report card will explain how CHP is currently rated for the following topics:

Staying Healthy
Living with Illness
Access & Service
Qualified Doctors and Providers

If you need additional resources for evaluating health care doctors and providers, check the following websites:

Advanced Directives & Living Wills

An advanced directive ensures that both medical professionals and your loved ones understand the end-of-life decisions you want in the event you’re unable to explain them due to a medical emergency. An advanced directive is simply a statement, made while you are competent, about the medical treatment you want if you can’t make those decisions later. Decisions made early and communicated plainly may have tremendous value for you and your family.

To obtain a copy of Five Wishes, an advance directive document that addresses all of an individual's needs (medical, personal, emotional, and spiritual), call Capital Health Plan's Health Information Line at (850) 383-3400 or download your copy of Five Wishes here. In addition, Aging with Dignity provides daily assistance or guidance on advanced care planning or help navigating challenging circumstances by calling 888-5-WISHES (594-7437) Monday- Friday 9 am-5 pm Eastern Time.

Health Information Line

The Health Information Line is a 24-hour a day phone line staffed by health care professionals who are able to assist you with your health-related questions. While not a substitute for a visit with your physician, the Health Information Line staff can provide you with tips, tools, and resources to help you manage your health. 850-383-3400 or 1-844-383-3400.

CHP About Your Care graphic

Amwell: Telehealth

Amwell is a faster, easier way to see a physician. You can have video visits with a doctor anytime via the web or mobile app. It's easy to use, private, and secure. It's free to enroll and the cost per visit is $15.00 Amwell can be used any time, day or night. It's perfect when traveing, your physician's office is closed, you're too sick to see someone in person, or you're looking for an alternative to a late-night ER or Urgent Care visit. Through Amwell, you can take care of the most common issues like colds, flu, fever, rash, sinusitis, ear infection, and pinkeye.

Clinical services on Amwell are provided by Online Care Group, the nation's first and largest primary care group devoted to teleheath. Physicians on Amwell average 15 years of experience in primary and urgent care and are U.S. Board Certified, licensed, and credentialed. You have the ability to view each physician profile so you can see their education and practice experience.

Enroll in Amwell today and use service key CHP.

For more information:

Wellness Programs

Capital Health Plan has created wellness programs to encourage members to adopt a healthier way of life and prevent the onset or worsening of an illness or disease. The ultimate goal is to make positive health practices the easiest choice. Capital Health Plan's Wellness Programs connect you to health classes supporting your commitment to a healthier lifestyle.

Wellness Reimbursement

The Wellness Reimbursement Program reimburses you for payments you have made (up to a maximum of $150) during the calendar year toward health/ fitness center or other qualified memberships for yourself or your covered dependents.

For commercial members, Capital Health Plan will reimburse only for the amount reflected on those receipts/statements up to $150 per family per contract.
For Medicare members, Capital Health Plan will reimburse only for the amount reflected on those receipts/statements up to $150 per member.
Federal employees, Federal Annuitants and their dependents are not eligible for this benefit.

Below is additional information on how the program works. Please check with your physician before starting your exercise program.

You must be a current Capital Health Plan member; and
You must be a current member of the health and fitness program in the requested period; or
You must be enrolled in either Weight Watchers, TMH Diabetes Prevention Program, Noom, or Take Off Pounds Sensibly (TOPS) in the requested period.
- For more information about the TOPS program, please call 800-932-8677 or visit www.TOPS.org.
Wellness reimbursement requests may only be filed once per calendar year and reimbursements for the previous year cannot be processed beyond December 31st of the current year. All reimbursements will be made to the subscriber (the person who holds the CHP policy).
Facilities and/or programs that DO qualify for reimbursement include gyms and fitness centers (i.e. YouFit, Premier, Momentum, etc.), internet or app based fitness subscription programs (i.e. Beachbody On Demand, Apple Fitness+, Peloton, Daily Burn, My Fitness Pal, etc.), gymnastic centers, personal trainers, sports teams or leagues, Weight Watchers, Noom, Headspace or Calm subscriptions, TOPS, or the TMH Diabetes Prevention Program.
Facilities and/or programs that DO NOT qualify for reimbursement include country or social clubs, spas, tennis facilities, uniforms/clothing, and exercise/fitness equipment.

To obtain your reimbursement, just send the following items to Capital Health Plan, Attn: Claims Department, P.O. Box 15349, Tallahassee, FL 32317-5349:

A signed and dated Wellness Reimbursement Form
All applicable receipts, credit card records, cancelled checks, and/or pay stubs that show payment to an approved health or fitness club

Questions?

Call Capital Health Plan Member Services.

Population Health

Within the Population Health Program, our Disease Management Programs offer comprehensive services to help members manage chronic conditions. Additionally, health and wellness education, decision support, and symptom management are available through Healthwise Knowledgebase and the CHP Health Information Line.

Disease management programs are designed to support and reinforce the treatment plans of each member's primary care physician. Program members are eligible to receive:
- Access to nurses and other health professionals who can assist with self-management.
- Educational materials, both printed and web-based, through Healthwise Knowledgebase.

CHP members are automatically enrolled when they are identified as having either diabetes or vascular disease.

Disease management programs are based on clinical practice guidelines approved by CHP’s Quality Improvement Committee.

Worry-Free Travel

Away From Home Care®

Capital Health Plan participates in Away From Home Care® (AFHC®) to cover routine and emergency care for members who are out of our service area for 90 or more consecutive days. Members can take advantage of the AFHC® benefit when families are apart, such as when a child is away at college, or during periods of long-term travel. Members should call Capital Health Plan Member Services to check their eligibility and to begin the application process.

You may also download the Away From Home Care Brochure.

BlueCross BlueShield Global Core® Program

When you travel outside CHP's service area, your coverage travels with you. The BlueCard BlueShield Global Core® Program, gives you access to participating providers and the independent BlueCross® and/or BlueShield® organizations throughout the world for both emergency and urgent care services. As with your CHP membership, you won't have to fill out any claim forms or pay up front when receiving services - as long as you use a participating provider.

You may also download the Blue Card Program Information Brochure.

Prenatal Care

As you make plans for the arrival of your baby, CHP would like to assist you in your preparations. If you would like to enroll in CHP’s Prenatal Program, please send a secure message via CHPConnect or call the Health Information Line at (850) 383-3400 or 1(844) 383-3400.

Below are some additional resources:

This web page is intended to highlight the Plan and does not constitute a contract. The precise benefits will be controlled by the contract and not by this web page. Services described will be provided at one of CHP’s Health Centers or in other designated network doctors and providers' offices or in facilities authorized by a CHP physician.

CHP provides maternity coverage without a qualifying waiting period, where the contract states. However, any costs incurred before your membership with CHP became effective are not covered.