SELECT YOUR PRIMARY CARE PHYSICIAN (PCP)
Choose a PCP for yourself and/or your dependents, Your PCP is your health care partner and central coordinator for your health care needs.
Go to capitalhealthplan.com and selected Find a Doctor/Provider, this will bring you to the provider directory where you can see in network providers. Follow the below steps:
- View our Doctor/Provider Directory.
- On the Doctor/Provider Directory, use the drop-down menu in the category labeled Accepting New Patients and select Yes.
- Next, use the drop-down menu in the category labeled Primary Care Physicians and select Yes.
- Click on the green Apply button.
- Review the list of PCPs accepting new patients and choose the one you would like to have as your primary care physician.
For added convenience, you may be interested in selecting a PCP from the Physician Group of Capital Health Plan at one of our three health centers.
You can also call member services at 850-383-3311 to see if the doctor is accepting new patients or to request a hard copy of the directory. In some cases, a doctor may not be taking new patients, and you may have to make another choice.
HOW TO OBTAIN SPECIALTY CARE
- Members have direct access to a network of specialists for office visits and consultations. Your PCP should be able to assist you for other services that may require a referral or prior authorization such as cardiology or behavior health.
- View our Doctor/Provider Directory to locate a specialist or practitioner in the Network by selecting from the Doctor or Provider Specialty drop-down menu.
HOW TO OBTAIN AFTER-HOURS CARE
- For after-hours care or if you physician is not available, please contact one of the Urgent Care centers in the CHP network.
- View our Facility Directory to find an Urgent Care location. Use the facility type drop-down menu and select Urgent Care to find the nearest urgent care facility to you.
- You may utilize the telehealth services available via Amwell,
- For emergencies, please call 911 or go to the nearest Emergency Room.
MEDICAL RECORDS
If you are selecting a new physician for yourself and/or your dependents, you will need to transfer all records to your new physician’s office. Please check with your previous physician’s office to obtain their policies and procedures on how to transfer your medical records to your new physician.
CHPCONNECT
- Capital Health Plan (CHP) offers our members the opportunity to access their CHP medical history, review and download benefit documents, request new ID cards, and to select a new PCP.
- Review your CHP benefit documents via CHPConnect for 24/7 access. You may also contact your benefit administrator or by calling CHP Member Services to request your documents to be mailed to you.
- Learn more about CHPConnect by clicking here.
ABOUT YOUR CARE
Learn about your care as a CHP member by clicking here.
To find information about care outside the service area, please refer to your member handbook or contact member services.
ABOUT YOUR MEDICATIONS
CHP works with a national pharmacy network to provide pharmacy benefits. When you purchase a covered prescription drug from a participating pharmacy, you will be required to pay a copayment. It’s important to note that not every plan offers prescription drug coverage; it's advisable to consult your benefit documents for further information.
To learn more about your pharmacy benefit, you can click here and find information on:
- Procedures that impact pharmaceutical coverage.
- How to access or review pharmaceutical lists.
- How to access or review restrictions on prescribing or accessing pharmaceuticals.
- The copayment structure for restricted pharmaceuticals.
- The policy for exceptions regarding coverage of nonformulary pharmaceuticals (if there is a closed formulary).
LABORATORY SERVICES
CHP offers laboratory services through LabCorp’s national network. To find a local LabCorp click here.
BENEFIT DOCUMENTS
To access your CHP benefit documents 24/7, simply scan the QR code found on the back of your CHP ID card or visit CHPConnect.
For additional assistance, you can reach out to your benefit administrator or call CHP Member Services to have your documents sent to you by mail.
SUBMITTING CLAIMS
Your doctor or provider will submit claims for covered services on your behalf, but you must present your CHP ID card. You can view your claim information via CHPConnect for 24/7 access or may call CHP Member Services.
SUBMITTING A COMPLAINT OR APPEAL AND EXTERNAL REVIEW RIGHTS
For details on appeals, grievances, and external review rights, click here.
To file a complaint or appeal, reach out to CHP Member Services. You may also refer to your Member Handbook for more details on the complaint, grievance and appeal process.
YOUR RIGHTS & PRIVACY
Understand your rights and privacy as a CHP member by clicking here.
You can also contact Capital Health Plan Member Services to request a physical copy of the Notice of Privacy Practices.
COORDINATION OF BENEFITS
The process of accurately coordinating benefits between more than one insurance plan enables CHP to ensure that claims are processed in both a timely and efficient manner. We ask that you please complete the Coordination of Benefits Questionnaire within the first 30 days of your CHP coverage. You can obtain a copy of this document by contacting your benefit administrator or by calling CHP Member Services.
LANGUAGE ASSISTANCE
For any member or prospective member in need of language assistance, should contact CHP Member Services. A member services representative can connect you with a contracted translation interpreter to communicate by telephone. Members requiring language assistance at one of our three health centers should notify the receptionist upon scheduling their appointment and assistance will be provided.
UTILIZATION MANAGEMENT\EVALUATION OF NEW TECHNOLOGY
To better understand how CHP makes health care decisions, along with evaluating new technology to ensure quality treatment and efficient use of resources, click here.
CHP conducts regular evaluations of emerging medical technologies, including drugs, procedures, and devices, to determine coverage eligibility. Members and healthcare providers can request the assessment of new technologies at any time. To understand the decision-making process and the criteria for approval, click here for more information.
COPAYMENTS, DEDUCTIBLES, AND COINSURANCE
Copayments
A copayment is a set amount you must pay when you get certain covered services. There are different types of copayments, and here's how they work:
- If the allowed amount or the provider's actual charge for a covered service is less than your copayment, you will pay the lower amount.
- Copayments must be paid at the time you receive the services, apply before any payment will be made by us, apply regardless of the reason for the service, and usually apply to all services rendered during the visit. However, there are exceptions to this rule, so be sure to check your Schedule of Benefits and the brief explanations below.
Example:
Anne goes to see her Primary Care Provider (PCP) because she feels dizzy when she works out. To see her doctor, she needs to pay a $25 copay. When Anne gets to the office, she hands the receptionist the $25. After her visit, her doctor sends her to a heart specialist. When Anne sees the cardiologist, she will have to pay her specialist copayment which is a $40 copay for that appointment, according to her insurance plan.
You can check your CHP ID card for a list of copays for different types of visits.
Deductible
A deductible is the amount of money you owe for covered health care services before your CHP health insurance begins to pay for healthcare services. Throughout the year of your plan, your payments add up until you reach your deductible.
Example:
David has a High Deductible plan with a deductible of $1,000, meaning CHP won't pay anything until he spends that amount on covered health care. He recently visited a specialist and had some tests that cost him $612. Now, he only needs to spend $388 more to meet his deductible.
Coinsurance
Coinsurance is the part of the cost you pay for a covered health care service. It is usually a percentage of the total amount allowed for that service.
Example:
Beth’s CHP plan requires a 20% coinsurance for non-admission Emergency Room (ER) visits.
Reminder: You can access your CHP benefit documents anytime, by scanning the QR code found on the back of your CHP ID card or through CHPConnect.
To learn more about these topics or if you have questions about your benefits and coverage, contact Capital Health Plan Member Services at 850-383-3311. 8:00 a.m. - 5:00 p.m., Monday - Friday Medicare members call (850) 518-6252 or 1 (877) 247-6512: 8:00 a.m. - 8:00 p.m., seven days a week.