How to Use Your Health Plan

Whether you're a member of the State's Basic Health, Healthy Options, or the Children's Health Insurance Program, the links below will help you learn the basics on how to use your health program. If you don't find the information you're looking for here, please consult your member handbook or contact Community Health Plan customer service at 1-800-440-1561 or here. They will be glad to help you.

Your ID Card

As a member of Community Health Plan, you should have been issued a member ID card. It should have come with a letter welcoming you to the plan. Every family member enrolled in the plan should have his or her own ID card. If you haven't received your ID card(s) within three weeks of joining, please contact Community Health Plan customer service at 1-800-440-1561.

You will need your Community Health Plan ID card for all visits to the doctor, hospital, and pharmacist. If you're a member of Healthy Options, you'll also need your medical assistance ID card (coupon) from DSHS.

Choosing a Primary Care Provider (PCP)

As a member of our plan, you need to choose a primary care provider, or PCP. Your PCP is your main health care provider. He or she can refer you to specialists if necessary. Everyone in your family can choose his or her own PCP. If you don't choose a PCP, we'll choose one for you.

For a list of PCP's to choose from, see your Community Health Plan Provider and Pharmacy Directory, which you should have received when you joined our plan. For more information, please contact Community Health Plan customer service at 1-800-440-1561 or here.

Your PCP: Your Partner in Health Care

Your primary care provider is your main provider, the one who helps you manage all aspects of your health. Always call your PCP first for your medical care, except in an emergency. (In an emergency, call 911 or go to the nearest hospital).

Your PCP's office or clinic may offer:

• Comprehensive medical services to help you and your family stay healthy.
• Referral to a specialist when you and your PCP agree you need one.
• Referral to hospital care when you need it.
• Medical advice by phone in most situations, even when the clinic is closed. (Please check with your provider's office or your clinic for more information.)
• Interpreters and assistance with transportation if you need those services on the day of your appointment.

Changing Your Primary Care Provider

You can change your primary care provider by calling Community Health Plan customer service at 1-800-440-1561.

Making an Appointment

To make an appointment, call your Primary Care Provider (PCP). Be sure to request an interpreter if needed. If you are a new member, please let your provider know when you make your first appointment.

Specialist Referrals

A specialist is a health care provider other than your PCP who offers a specific kind of medicine—a surgeon, a physical therapist, or a mental health counselor, for example.

If you and your PCP agree that you need to see a specialist, your PCP will provide you with a written referral to a specialist covered by Community Health Plan. Specialist care is covered only when you've been referred by your PCP. In some cases, your specialist care must be approved by us before you receive it—this is called prior authorization. If you have a complex or serious medical problem, you have the right to a referral that continues for a long period of time. This is called a standing referral.

For a list of specialists covered under our plan, contact our customer service representatives here or at 1-800-440-1561.

Hospital Referrals

If you need to go to the hospital for non-emergency care, you must first get a referral from your PCP. You do not need a referral to visit a hospital in an emergency. In an emergency, go to the hospital nearest you or call 911. Remember that you or someone you know must notify your PCP within 24 hours of your emergency or as soon as is medically reasonable.

Getting a Second Opinion

Sometimes it's a good idea to get a second opinion concerning a diagnosis or treatment plan. As a member of Community Health Plan, you have a right to a second opinion. For the second opinion to be covered by your insurance, second opinion providers must be part of our network; in addition, a referral from your PCP may be required. To obtain a second opinion, you can:
• Ask your PCP for the name of another qualified Community Health Plan provider, or
• Call Community Health Plan customer service at 1-800-440-1561 or contact them here to ask for the names of qualified providers.

Filling a Prescription

Your plan covers many pharmacy chains and neighborhood drugstores where you can have your prescriptions filled. For a list of pharmacies, please see the Community Health Plan Provider and Pharmacy Directory. Or call our customer service representatives at 1-800-440-1561.

If you need a 30-day supply of a regular prescription before you go on vacation, please consult with your PCP before you leave. If you need more than a 30-day supply, please call Community Health Plan customer service at 1-800-440-1561. Non-emergency, out-of-state prescriptions are not covered.

State and federal laws set standards for safe and effective pharmacy service. They also give you the right to know what pharmacy services are covered by your plan. If you'd like more information about our pharmacy coverage, read through some pharmacy frequently asked questions or call Community Health Plan customer service representatives at 1-800-440-1561 or contact them here.

Services for Persons Who Are Hearing- or Speech-Impaired

Please call us Monday through Friday, 8 a.m. to 6 p.m., at our toll-free TTY phone line: 1-800-833-6388.

When You're Sick or Your Child Is Sick

When you're sick, or when you have a sick child, call your PCP. Your PCP can often treat minor problems faster than the emergency room can, and most PCP's offer after-hours medical advice by phone.

If symptoms are severe or you can't reach your PCP, go to an urgent care center or to the emergency room. You must notify your PCP within 24 hours or as soon as your medical condition allows.

Well-Child Visits and Free Bike Helmets through the Community Health Plan Children First program

At Community Health Plan, we care about your health and safety. As part of the Community Health Plan Children First program, we’re proud to provide eligible members a free bike helmet or helpful health book when they complete a well-child exam. To be eligible, your child must:

• Be a member of Community Health Plan;
• See his or her provider for their scheduled well-child exam;
• Be current on all scheduled immunizations;
• Be between newborn and 3 years of age to receive a free Healthwise Handbook; or
• Be between 4 and 13 years of age to receive a free bike helmet.

Please contact Community Health Plan customer service at 1-800-440-1561 for details. If you are hearing-or-speech impaired, please call 1-800-833-6388.

Preventing injuries and illness is one of the best ways to maintain the health of your child. During well-child exams, your provider will monitor the growth and development of your child, as well as keep his or her immunizations up to date.

To help make sure your child is safe when he or she uses the helmet, carefully read the instruction manual and follow all directions for the correct and safe use of the helmet. The manufacturer's warranty is the only warranty for the bike helmet, and Community Health Plan makes no additional warranties for the product.

In an Emergency

If you think you have an emergency, call 911 or your local police department or go to the nearest hospital. If you have questions about what is considered an emergency, please talk to your PCP.

You do not need a referral from your PCP for an emergency room visit. However, you or someone you know must call your PCP within 24 hours after your emergency room visit or as soon as your medical condition allows. Tell your PCP what happened and make a follow-up appointment if necessary.

Health Coverage When You Travel

Relax—Community Health Plan covers you for emergency care, urgent care, and follow-up care that can't wait until you return home and is medically necessary. We also cover prescription drugs needed for emergency treatment.

If you have an emergency while traveling, go to the nearest hospital emergency room. Please notify your PCP within 24 hours after your emergency or urgent care or as soon as your medical condition allows. Your follow-up care will be covered only if it is first approved by your PCP or by Community Health Plan.

If you need a 30-day supply of a regular prescription before you go on vacation, please consult with your PCP before you leave. If you need more than a 30-day supply, please call our customer service representatives at 1-800-440-1561. Non-emergency, out-of-state prescriptions are not covered.

If You Are Pregnant You Could Receive a Free Car Seat through the Community Health Plan Children First program

Early prenatal care—the medical care you get while pregnant—is essential for your health and the health of your baby. Call your primary care provider for a checkup as soon as you know you are pregnant. During your pregnancy, tell your provider about any special needs, concerns, or questions you have.

It's best to choose a primary care provider for your baby while you are pregnant. If you don't choose one by the time your baby is born, we'll choose one for you. You can change your baby's PCP later if you wish.

Free Car Seat through the Community Health Plan Children First program

Your health and the health of your new baby are important to us. If you have maternity benefits you could be eligible to receive a free car seat for your new baby as part of the Community Health Plan Children First program! To be eligible, you must:

Be a member of Community Health Plan;
Be pregnant; and
See your provider within the first three months of pregnancy;
OR if you are new to Community Health Plan, see your provider within 42 days of joining Community Health Plan.

Please contact Community Health Plan customer service at 1-800-440-1561 for details. If you are hearing-or-speech impaired, please call 1-800-833-6388.

Once your baby is born, remember to schedule regular checkups with your provider. During these visits, your baby will receive important immunizations and your provider will monitor your baby's growth and development. Don't forget to ask your provider any questions you might have as a new parent—your provider is interested in helping your baby grow up to be a happy, healthy child.

To help make sure your child is safe when he or she uses the car seat, carefully read the instruction manual and follow all directions for the correct and safe installation and use of the car seat. We'll also send you some additional information on car seat safety. The manufacturer's warranty is the only warranty for the car seat, and Community Health Plan makes no additional warranties for the product.

First Steps Program

During your pregnancy, you may be eligible to receive the following services through Washington State's First Steps program:

• Nursing services
• Social work services
• Health education and counseling
• Child care and transportation for maternity appointments
• Nutritional services

You can get more information about the First Steps program from your primary care provider or from a Department of Social and Health Services Community Service Office. Or call the Healthy Mothers, Healthy Babies Coalition of Washington at 1-800-322-2588.

Where to Mail Your Premium

Please send your premiums, on time, to the agency that administers your particular plan. You should not mail your premiums to Community Health Plan.

What Is an Explanation of Benefits (EOB)?

After you receive health care under our plan, we'll mail you a written explanation of benefits, or EOB. It will explain what services we paid for and show any amount you are responsible for paying.

If You Need an Interpreter

We can provide you with an interpreter when you need to contact Community Health Plan. If you'd like an interpreter, please call us Monday through Friday, 8 a.m. to 6 p.m., at 1-800-440-1561. Tell the customer service representative what language you speak, then please stay on hold until you are connected to someone who can help you.

Native American Health Care Services

If you are Native American, you can receive covered services from the Indian Health Care System (IHCS). Call our customer service representatives at 1-800-440-1561 for information.

If You Have a Complaint

Your complaints and concerns are important to us, and we want to hear about them. If you have a grievance, please call our customer service representatives toll-free at 1-800-440-1561. If a customer service representative can't resolve your grievance, or if you aren't happy with the response you get, please send your grievance in writing to:

Grievance Coordinator
Community Health Plan
720 Olive Way, Suite 300
Seattle, WA 98101-1830

In your letter, please include your name, address, subscriber ID number, the reason for your grievance, and any other information you think is important.

Our grievance coordinator will let you know within five days that your letter has been received. We will then review your grievance and respond within 14 days of receiving it. It's possible that the initial answer you receive could be a notice of a delay in the grievance resolution. If there is a delay, we will explain why and tell you when you can expect a final decision. We will make a decision about your grievance within 30 days of your initial request, unless we get your written permission to take more time.

Appealing Our Decision

If you don't agree with our resolution of your grievance, and if our resolution includes a decision to deny, modify, reduce, or terminate coverage or payment for a health care service, you can ask that an independent review organization (IRO) review your grievance. The IRO will be selected by the office of Washington State's insurance commissioner. This office has no connection with Community Health Plan. Once the IRO has made a decision, it will contact you directly and explain its decision. The IRO decision is final.

If our resolution of your grievance includes a decision to change, reduce, or stop a medical service because we determine that the service is no longer medically necessary or appropriate, you can ask us to keep paying for the service while the IRO reviews our decision. If the IRO decides that our original decision was correct, you may have to repay the cost of those services.

Expedited Grievance Review

If your doctor believes a delay in care could seriously hurt your health or your ability to regain maximum function, we will review your grievance quickly. Your doctor will speak with our medical director or with our medical director's representative. Our medical director may also speak with others related to your case and then will make a decision within 72 hours. Our medical director will then inform your doctor, who in turn will inform you.

If you don't agree with our first-level decision about your grievance, and if our resolution includes a decision to deny, modify, reduce, or terminate coverage or payment for a health care service, you or your authorized representative can ask for an expedited review from an independent review organization (IRO). The IRO will then make a decision within 72 hours of receiving all needed information or within eight working days after receipt of your grievance, whichever is earlier. The IRO will contact you directly within two working days and explain its decision.

At any time during this process, if you are a HO, CHIP or BHP Plus member, you can appeal to Washington State's Department of Social and Health Services. You can file a fair hearing request or complaint by:

Contacting your DSHS Community Service Office and speaking with the person responsible for fair hearings, or
Writing to:
Office of Appeals
Department of Social and Health Services
P.O. Box 2465
Olympia, WA 98507-2465

If you have any questions about this procedure, please call our customer service representatives at 1-800-440-1561.