Authorizations & Referrals
A referral is the process of sending a patient to another practitioner (ex. specialist) for consultation or a health care service that the referring source believes is necessary but is not prepared or qualified to provide. Your primary care physician will refer you to a participating specialist or a health care service provider if he or she cannot personally provide the care you need. Many referrals do not require an authorization number.
Prior authorization is a process that requires either your provider or you to obtain approval from Capital Health Plan before receiving specific items and services. When prior authorization is required, Capital Health Plan reviews the request and your plan benefits. If the specific item or service is a covered benefit in your plan (refer to your member handbook for member-specific benefit information), we then use 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.
Who is responsible for obtaining prior authorizations?
Typically, your primary care physician (PCP) or the specialist you are seeing will obtain prior authorization on your behalf. However, it is also your responsibility to ensure that the authorization is in place prior to receiving the item or service. All requests for prior authorization are processed and a determination is rendered and 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.
We have built a list detailing which items and services require prior authorizations for your convenience.
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.
- Consumer Health Information: Agency for Healthcare Research & Quality
- Consumer Safety Information: National Patient Safety Foundation
- Consumer Health Information: Food & Drug Administration
- Hospital Safety Scores: The Leapfrog Group
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.
- QI Commercial Program Description
- QI Medicare Program Description
- QI Program Evaluation
- QI Behavioral Health Program Description
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 Providers
If you need additional resources for evaluating health care providers, check the following websites:
- Quality Report Cards for Physicians: Health Grades
- Quality Report Cards for Hospitals: Health Grades
- NCQA Health Plan Ratings
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.
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:
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.
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 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, 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
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.
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.
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:
- General pregnancy information
- Feeding your baby
- FAQ about pregnancy
- Healthwise Knowledgebase®
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 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.