FREQUENTLY ASKED QUESTIONS BY DOCTORS AND PROVIDERS

How do I know which hospitals and specialists are in-network to refer patients to?

You can verify in-network hospitals and/or specialists by searching our provider/facility directory.

Are there any preferred providers or facilities within the network? 

The Physician Group of CHP is available for primary care services at our three member-exclusive Health Centers. Our health centers also provide additional services such as eye care, mammography, ultrasound, x-ray, routine labwork, and more. When medically appropriate, physicians may send their patients for care at one of our three health centers. For a full list of providers and facilities, please see our Provider Directory.

How can I verify a patient’s eligibility and benefits?

Providers can verify their patients eligibility via the CHPConnect portal or by contacting Network Support Services.

Are there any specific forms or documentation I need to submit for pre-authorization? What is the process for obtaining prior authorization for covered services?

Providers must utilize the Universal Prior Authorization Form and complete it in full. Incomplete forms will not be considered a valid request for services and therefore will not be processed. All requests for prior authorization are processed and a determination is communicated within 15 calendar days of receipt of all necessary information. Find more information on referrals and authorizations here.

What is the process for appealing a denied claim? What are the plan’s appeal processes and timelines?

If we deny a request, we will send a written decision explaining the reason(s). If we deny all or any part of a request in our organization determination, members or providers who have been Appointed as a Representative may ask us to reconsider our decision. This is called an “appeal” or “request for reconsideration.” An appeal to our denial must be filed within 60 calendar days of the date on the notice of our organization determination. We can provide more time if there is a good reason for missing the deadline.

An appeal should include the patient name, address, member ID number, reasons for appealing, and any evidence that the patient would like to attach, such as:

• Supporting medical records
• Doctors’ letters, or
• Other information that explains why we should provide the service

Patients may send the information in with their appeal or drop it off in person at one of our Health Center locations.

If the patient’s appeal relates to a decision by us to deny a drug that is not on our list of covered drugs (formulary), the provider, doctor, or other prescriber must indicate that all of the drugs on any tier of our formulary would not be as effective to treat your condition as the requested off-formulary drug or would harm your health.

Can you provide me with a copy of the plan’s formulary (list of covered medications)?

Formularies are dependent on your patient’s specific member plan. You will need to know what type of plan your patient has and then locate their specific plan information here.

Can you provide me with a list of resources or contacts for questions regarding the plan?

You can access our Provider focused Network Support Services page or directly call our Network Support Services at (850) 523-7361

How can I cover my newborn from birth?

You should submit the Member Status Change Form to your benefit administrator 60 days prior to the date of birth or during the 60-day period immediately following the date of birth. The effective date of coverage would be from the date of birth for the newborn.

Can I cover a dependent who lives out of state or is away at school?

Yes. Capital Health Plan participates in the 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. Click here to learn more about AFHC®.

How can I manage my practice electronically with CHP?

CHP offers multiple ways to manage your practice electronically:

• Electronic Claims Submission
• Direct Deposit
• CHPConnect

Providers may also contact Network Services for additional information.

How do I submit claims electronically to the plan?

Learn more about electronic claims submission on our Electronic Claims Submission section of the Network Support Services page.

What are the plan’s rules regarding electronic claims submission?

CHP currently accepts electronic claims submissions through several clearing houses and provider offices must follow the submission guidelines in our EDI Companion Guide. For more information, view our process here.

How can I stay up to date on information relevant to my practice?

CHP’s Network Services publishes Network News, our provider newsletter providing guidance, updates and information about Capital Health Plan. This information is accessed through CHPConnect. If you are not receiving notifications for your practice and are a provider within our network, you can request to be added to the distribution list by emailing Network Services.

Where can I find CHP’s Clinical Criteria?

View CHP’s clinical criteria page here.

What is CHP’s Case Management Program?

Learn about CHP’s Case Management Program here.