About How to Find and Work With Providers, Clinics, Pharmacies, Hospitals

 

Q. How do I choose a primary care provider (PCP)?

A. As a member of our plan, you need to choose a primary care provider, or PCP. Everyone in your family can choose his or her own PCP. If you don't choose a PCP, we'll choose one for you.

Click here to request a provider.

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.) He or she can refer you to specialists if necessary.

For a list of PCPs to choose from, see the Community Health Plan Provider and Pharmacy Directory, which is mailed to you when you join our plan. Members and others can also search our online provider directory. For more information, please contact Community Health Plan customer service at 1-800-440-1561 or email us at customercare@chpw.org.

Q. I'm considering joining Community Health Plan. As a member, will I be able to continue seeing my current primary care provider?

A. We contract with more than 2,365 primary health care providers and more than 13,571 specialists. To find out if your current provider is affiliated with Community Health Plan, call our customer service team at 1-800-440-1561 or email us at customercare@chpw.org.

Q. I have a baby. If I join Community Health Plan, who will be my baby's primary care provider?

A. Your primary care provider (PCP) will also be your baby's PCP. If you want a different provider for your baby, tell your clinic or call Community Health Plan customer service at 1-800-440-1561 and we will assign a provider to your child. Remember, the provider must be part of our service network.

Click here to request a provider for your baby.

Q. How do I change my primary care provider?

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

Or click here to request a change in provider.

Q. Is there a Community Health Plan clinic in my area?

A. We have more than 540 primary care clinics in Washington State. To find a clinic or provider in your area:

  • See the Community Health Plan Provider and Pharmacy Directory. The directory is mailed to each enrollee. If you need another copy of the directory, please contact our customer service team.
  • Visit the Community Health Plan online provider directory, which is updated as provider lists change.
  • Contact the Community Health Plan customer service team at 1-800-440-1561 (toll free) or email us at customercare@chpw.org. If you are hearing or speech impaired, please call TTY 1-866-816-2479 (toll free) or local 206-613-8875.

Q. Where can I get my prescriptions filled?

A. Your plan covers many pharmacy chains and neighborhood drug stores where you can have your prescriptions filled.

To get a list of pharmacies in the Community Health Plan network:

  • See the Community Health Plan Provider and Pharmacy Directory.
  • Search for a drug store near you by activating and using your ESI account.
  • Contact the Community Health Plan customer service team at 1-800-440-1561 (toll free) or email us at customercare@chpw.org. If you are hearing or speech impaired, please call TTY 1-866-816-2479 (toll free) or local 206-613-8875.

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.

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 email us at customercare@chpw.org.

Q. As a member of Community Health Plan, which hospital will I go to?

A. We contract with more than 100 hospitals throughout the state. Your primary care provider can help you choose one.

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.

Q. What happens when I need to see a specialist?

A. 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. However, you may choose and see a women's health care specialist in the Community Health Plan network without a referral from your PCP.

In some cases, your specialist care must be approved by us before you get the care. 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 the Community Health Plan customer service team at 1-800-440-1561 or email us at customercare@chpw.org.

Q. How do I get a second opinion?

A. 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 get a second opinion, you can:

  • Ask your PCP for the name of another qualified Community Health Plan provider, or
  • Ask us for the names of qualified providers. Call the Community Health Plan customer service team at 1-800-440-1561 or email us at customercare@chpw.org.

How do I get care from specialists and other network providers?

A. A specialist is a doctor who provides health care services for a specific disease or part of the body. There are many kinds of specialists. Here are a few examples:

  • Oncologists, who care for patients with cancer.
  • Cardiologists, who care for patients with heart conditions.
  • Orthopedists, who care for patients with certain bone, joint, or muscle conditions.
  • Behavioral health clinicians, who treat mental health issues and substance abuse.

When your PCP thinks that you need specialized treatment, he/she will give you a referral (approval in advance) to see a Plan specialist or certain other providers.

For some types of referrals, your PCP may need to get approval in advance from our Plan (this is called getting "prior authorization"). It is very important to get a referral (approval in advance) from your PCP before you see a Plan specialist or certain other providers (there are a few exceptions, including routine women's health care). If you don't have a referral (approval in advance) before you get services from a specialist, you may have to pay for these services yourself.

If the specialist wants you to come back for more care, check first to be sure that the referral (approval in advance) you got from your PCP for the first visit covers more visits to the specialist.