Coordination of Care

What is a Primary Care Provider?

A primary care provider (PCP) is the doctor you see the most. Different kinds of practitioners can be PCPs, including:

• Family Practice and General Practice doctors who treat adults and children
• Internal Medicine doctors or Internists who treat members over the age of 18
• Pediatricians who treat children from birth to age 21
• Certified Registered Nurse Practitioners (Nurse Practitioners)

You can choose the same PCP for your whole family if everyone has similar health needs, or you can have a different PCP for each family member if each person has different health concerns.

How do I choose a PCP if I don't have one?

1. Use the online Provider Search Tool to find a doctor that best meets your needs. CareFirst CHPMD will also mail you a printed provider directory upon request.
2. You may also call Member Services at 410-779-9369 or 800-730-8530 (TTY: 711) for help finding a doctor. Members who don't speak English can call 800-730-8530 to ask for an interpreter.
3. Call the doctor's office and schedule an appointment.

Why is choosing a PCP important?

Establishing a relationship with a PCP is the best way to receive consistent, quality care and ensure your healthcare experience is the best it can be. They play a huge role in keeping you healthy now and in the long run.

Your PCP:

• Has online access to your medical records from all your doctors, including lab results and prescriptions
• Makes sure you get the care you need when you need it
• Reviews all your medications for any possible drug interactions or duplications
• Develops a personalized plan of care for any health problems
• Helps you coordinate the care you may need with other providers, such as a visit with a specialist, X-rays or lab work

Some illnesses and injuries can become an emergency if not treated within 48 hours. These conditions may require urgent care.

Some examples are:

• Ear infections
• Urinary tract infections
• Coughs and congestion
• Diarrhea
• Sore throats
• Insect bites
• Rashes

Members may visit their doctor or a CareFirst CHPMD network Urgent Care Center.

Because you never know when you'll need care, CareFirst CHPMD offers options that are available anytime, day or night. Through CloseKnit, you have access to 24/7/365 virtual-first primary care, preventive care, urgent care, primary mental health, nutrition and other specialty services.

You can also call the 24-Hour Nurse Advice Line at 800-231-0211 for general questions about health issues or where to go for care.

If you call your PCP's office when it's closed, leave a message with your name and a telephone number where you can be reached when they reopen.

Call 911 or immediately go to the nearest emergency room (ER) for emergency care. If you're unsure if you should go to the ER, call your PCP for advice. Except for emergencies and urgent care when traveling outside the service area, CareFirst CHPMD will not pay for services you receive from non-CareFirst CHPMD doctors and facilities.

What is an emergency?

An emergency is when not seeing a provider right away to get care could result in death or very serious bodily harm. The problem is so severe that someone with an average knowledge of health can tell the problem may be life-threatening or cause serious damage to your body (or, for pregnant individuals, the health of themselves or their unborn child).

Some examples of problems that are most likely an emergency are:

• Trouble breathing
• Chest pains
• Loss of consciousness
• Very bad bleeding
• Very bad burns
• Severe pain

You should call your PCP within 24 hours after you visit the emergency room. If you can't call, have someone else call for you. Your PCP will provide or arrange any follow-up care you may need.

If you need urgent or emergency care when you are out of town, go to the nearest urgent care center or hospital emergency room or call 911. If you need routine care like a checkup or prescription refill when you are out of town, call your PCP or our Member Services Department at 410-779-9369 or 800-730-8530 (TTY: 711) from 8 a.m.–5 p.m., Monday–Friday.

If you are under 21, you are eligible for eye exams and glasses once a year or contact lenses if medically necessary. If you are 21 and over, you are eligible for eye exams every two years. For more information, look up Vision Care in our Member Handbook.

If you have questions or need help finding an eye doctor, contact Member Services at 410-779-9369 or 800-730-8530 (TTY: 711) from 8 a.m.–5 p.m., Monday–Friday.

When you are pregnant or suspect you are pregnant, it is very important that you call the CareFirst CHPMD. They will help you get the care needed during pregnancy, such as regular checkups with an obstetrician (OB doctor) or certified nurse midwife to monitor your and your unborn baby's health.

If you have questions or need any help, contact Member Services at 410-779-9369 or 800-730-8530 (TTY: 711) from 8 a.m.–5 p.m., Monday–Friday and ask to speak to a care manager.

For more information, see Getting Into Care in our Member Handbook.

Certain medical services and supplies require approval before they will be covered by your plan. All prior authorization requests are coordinated through your doctor's office. Your doctor must ask for and receive approval before you receive certain care.

CareFirst CHPMD will review the service, drug or equipment for medical necessity. If prior authorization is not given, coverage for care, services or supplies may be limited or denied. Any costs for denied services resulting from an in-network provider failing to receive prior authorization are not your responsibility. For more information on prior authorization guidelines through your plan, see your Member Handbook.

If you have a question, Member Services can be reached at 410-779-9369 or 800-730-8530 (TTY: 711), Monday–Friday, 8 a.m.–5 p.m. You can also email us at CHPMDHealthServices@carefirst.com. Members who don't speak English should call 800-730-8530 to ask for an interpreter.

Call CareFirst CHPMD.

410-779-9369
800-730-8530

8 a.m.–5 p.m., Monday–Friday

TTY users, please dial 711.
Please call 800-730-8530 to ask for an interpreter for members who don't speak English.