Member FAQs

To make an appointment, call your clinic or doctor’s office. If you need help locating the phone number or finding a doctor, use our provider directory. Remember, CHPW Individual & Family is an Exclusive Provider Organization (EPO) plan, which means that we cover services only when you receive them from Network Providers, with limited exceptions such as emergency care.

When you call to make an appointment:

• Tell them you’re a CHPW Individual & Family member.
• Ask for an interpreter if you need one.
• Have your CHPW Member ID handy.

Need help making an appointment? Call our Customer Service team 1-866-907-1906 (TTY: 711), Monday through Friday, 8 a.m. – 5 p.m.

You can get care in a variety of ways. The type of care you seek largely depends on your medical issue.

• Primary Care Provider: See your primary care provider for routine care like checkups and immunizations, if you’re managing a chronic illness, if you need a referral to a specialist, or if you get something like mild allergies or a cold and don’t need immediate attention.
• Nurse Advice Line: CHPW members have access to advice from professional nurses 24 hours a day, seven days a week at 1-866-418-2920 (TTY: 711). The Nurse Advice Line, powered by CHPW, can help you decide what type of care to seek.
• Virtual Care: Some health care providers and clinics offer doctor’s visits over phone or video. If your provider’s office doesn’t offer virtual care (also known as telehealth or telemedicine) or is closed, you can connect with a doctor at any time through CHPW’s 24/7 telehealth service, CHPW Virtual Care.
• Urgent Care: Urgent care offers non-emergency care 24 hours a day. It helps fill a vital gap for when you become sick or injured but your regular doctor is not available and you can’t wait for an appointment. Examples of urgent care issues: You suddenly get a fever, you experience vomiting or persistent diarrhea, you have small cuts that may require stitches.
• Emergency Room: The emergency room is open 24 hours a day, seven days a week. It is for serious injuries or issues with life-threatening symptoms. Some examples of issues that would need emergency care are: severe burns, auto accidents, shortness of breath, chest pain, severe stomach pain, bleeding that won’t stop.

Cost information is available for common inpatient and outpatient treatments, diagnostic tests, and office visits. Members can access estimated costs for treatment:

• Online with our Treatment Cost Calculator
• By phone with our Customer Service team at 1-866-907-1906 (TTY: 711), Monday through Friday, from 8 a.m. to 5 p.m.

Yes, if you paid out of pocket for a health expense that you believe we should cover, you can ask us to pay you back. You must complete the Member Claim Reimbursement Form, submit it along with your bill and payment documentation within 12 months, and ensure all referral and authorization requirements are met.

You have the right to get a second opinion.

Tell your primary doctor that’s what you want. They will refer you to a different provider, or you can choose one from our directory. Coverage, including the amounts you are responsible to pay, depends on whether you see an in-network or out-of-network provider.

Utilization management is a process of reviewing whether care is medically necessary and appropriate for patients.

We evaluate care before it’s given (prior authorization), while it’s given (concurrent review), and after it’s given (post-service review). Certain services, such as visiting a PCP or an in-network specialist, do not require utilization management review.

The review is done by the appropriate licensed staff, which includes nurses, social workers, pharmacists, and physicians. CHPW staff is available to discuss any utilization management process, authorization, or denial. All inpatient admissions and certain outpatient services and procedures require prior authorization.

Typically, for a standard request, we must make a decision and provide notification within five calendar days of receiving the request from your doctor. If we need more information from your provider, this time is extended. You will be notified via mail once a decision is made.

In some instances, your provider may determine that coverage of a certain request should be decided urgently. Urgent requests will have a decision timeframe of within two calendar days of receipt of the request from your doctor. If we need more information from your provider, this time is extended.

As a CHPW member, you must choose an in-network Primary Care Provider (PCP) to get your medical care, with limited exceptions such as emergency care and cases where you have obtained prior authorization from your PCP. If a covered service is not available from a network provider, your PCP will assist you in getting a referral to an appropriate out-of-network provider. When you get a referral to an out-of-network provider, you will be covered the same as with an in-network provider.

You can change your doctor from one in-network CHPW provider to another at any time:

• Call us. Our Customer Service team will be happy to help you change doctors.
• Log into your Member Center account and change your doctor online.

Each year, we publish a formulary, or list of covered drugs. You should review this list to determine what tier your drug is on and if there are any restrictions on it.