How to choose and see a provider
When you join Santa Clara Family Health Plan Cal MediConnect Plan (Medicare-Medicaid Plan) (SCFHP Cal MediConnect), one of the first things to do is choose your primary care provider (PCP). You can choose any PCP who is in our network and is accepting new members.
If you need to see a specialist, you may need a referral from your PCP. You may also need approval in advance from SCFHP Cal MediConnect. This is called prior authorization. See the SCFHP Cal MediConnect Member Handbook, Chapter 3, for information about referrals, and Chapter 4, for information about what services need prior authorization. Find the SCFHP Cal MediConnect Member Handbook in Member Materials.
Find a Doctor
The SCFHP Cal MediConnect Provider and Pharmacy Directory is a list of health care professionals that you may see as an SCFHP Cal MediConnect member. We also list pharmacies you may use to get your prescriptions. Providers are listed alphabetically by city.
You can request an SCFHP Cal MediConnect Provider and Pharmacy Directory by clicking here or call SCFHP Cal MediConnect Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m.
You can make a standing request to get this document in a language other than English or in an alternate format. We will keep this information on file for future mailings. You do not need to make a separate request each time. To make or change your request, call SCFHP Cal MediConnect Customer Services, submit an online request, or send a request in writing to:
Attn: Customer Service Department
Santa Clara Family Health Plan
PO Box 18880
San Jose, CA 95158
NOTE: SCFHP contracts with many providers throughout Santa Clara County. Some SCFHP Cal MediConnect providers may have been added or removed from our network after the directory was printed. To get the most up-to-date information about SCFHP Cal MediConnect providers in your area, use our Find-a-Doctor search tool, or call SCFHP Cal MediConnect Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m.
Frequently asked questions
Your PCP is the provider who takes care of you and is the first person you see when you need care, unless it is an emergency. You will get your routine or basic care from your PCP. Your PCP will coordinate the rest of the covered services you get from SCFHP Cal MediConnect, including:
- Laboratory tests
- Care from doctors who are specialists
- Hospital admissions
- Follow-up care
In some cases, your PCP may need to get prior authorization (prior approval) from SCFHP for certain services.
You can choose any PCP who is in our network and is accepting new members. Click here to find a PCP in the Cal MediConnect network. When choosing a PCP, you may want to choose a provider:
- That you see now, or
- Who has been recommended by someone you trust, or
- Who speaks your language, or
- Whose offices are easy for you to get to
A downloadable copy of the Provider and Pharmacy Directory is available in the Resources section on the right side of this page. You can also go to Member Materials to view or download the SCFHP Cal MediConnect Provider and Pharmacy Directory in multiple languages.
If you do not select a PCP, SCFHP will choose one for you and notify you.
- If you want help in choosing a PCP, please call SCFHP Cal MediConnect Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m.
You may change your PCP for any reason, at any time. Also, it’s possible that your PCP may leave our plan’s network. If your PCP leaves our plan network, we can help you find a new PCP in our plan network.
If your PCP change is approved, the change will usually be effective the first day of the next month. For example, if your PCP change is approved in February, in most cases, you can visit your new PCP on March 1. We will mail you a new SCFHP Cal MediConnect member ID card with the name of your new PCP on it. Once you get your new SCFHP Cal MediConnect ID card, we ask that you destroy your old SCFHP Cal MediConnect ID card(s).
A specialist is a doctor who provides health care for a specific disease or part of the body. There are many kinds of specialists. Here are a few examples:
- Oncologists care for patients with cancer.
- Cardiologists care for patients with heart problems.
- Orthopedists care for patients with bone, joint, or muscle problems.
Your PCP may refer you to specialists or other health care providers if you need services your PCP cannot provide. For some types of services, prescription drugs, or to see an out-of-network provider, your PCP, specialist, or other provider may need to get approval in advance from SCFHP. This is called getting prior authorization. See Chapter 4 of the SCFHP Cal MediConnect Member Handbook for more information on which services require prior authorization. Find the SCFHP Cal MediConnect Member Handbook in Member Materials.
If the specialist or other network provider wants you to come back for more care, check first to be sure the prior authorization you get for the first visit covers more visits to the specialist. Call SCFHP Cal MediConnect Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m.
If medically necessary specialized services are not available from a provider in the SCFHP Cal MediConnect network, you may get these services from an out-of-network provider. Your primary care provider (PCP) is responsible for submitting prior authorization requests for out-of-network services.
NOTE: If you go to an out-of-network provider, the provider must be eligible to participate in Medicare and/or Medi-Cal.
- We cannot pay a provider who is not eligible to participate in Medicare and/or Medi-Cal.
- If you go to a provider who is not eligible to participate in Medicare, you must pay the full cost of the services you get.
- Providers must tell you if they are not eligible to participate in Medicare.
For more information about getting care from out-of-network providers (including a list of services you can get without first getting approval from your PCP), see Chapter 3, Section D of your SCFHP Cal MediConnect Member Handbook. Find the SCFHP Cal MediConnect Member Handbook in Member Materials.
Long-term services and supports (LTSS) are services that help improve a long-term medical condition. Most of these services help you stay in your home so you don’t have to go to a nursing home or hospital. LTSS includes the following:
- Community-Based Adult Services (CBAS)
- Health and social services provided at a licensed, community-based health center
- Multipurpose Senior Services Program (MSSP)
- Care management with connection to home & community-based services that help seniors aged 65+ live independently
- Nursing Facilities (NF)
- Facilities that provide care for people who cannot safely live at home but who do not need to be in the hospital
Your case manager will help you understand each program. To find out more about any of these programs, contact SCFHP Cal MediConnect Case Management at 1-877-590-8999 (TTY: 711), Monday through Friday, 8:30 a.m. to 5 p.m.
If SCFHP Cal MediConnect is new for you, you can keep seeing the doctors you go to now for a certain amount of time. You can keep your current providers and service authorizations at the time you enroll for up to 12 months if all of the following conditions are met:
- You, your representative, or your provider makes a direct request to us to continue to see your current provider.
- We can establish that you had an existing relationship with a primary or specialty care provider, with some exceptions. When we say existing relationship, it means that you saw an out-of-network provider at least once for a non-emergency visit during the 12 months before the date of your initial enrollment in SCFHP Cal MediConnect.
- We will determine an existing relationship by reviewing your health information available to us or information you give us.
- We have 30 days to respond to your request. You may also ask us to make a faster decision and we must respond in 15 days.
- You or your provider must show documentation of an existing relationship and agree to certain terms when you make the request.
Note: This request cannot be made for providers of Durable Medical Equipment (DME), transportation, other ancillary services, or services not included under Cal MediConnect.
After the continuity of care period ends, you will need to see doctors and other providers in the SCFHP Cal MediConnect network unless we make an agreement with your out-of-network doctor. A network provider is a provider who works with the health plan. See Chapter 3, Section B of the SCFHP Cal MediConnect Member Handbook in Member Materials for more information on getting care.
To request continuity of care:
- Call SCFHP Cal MediConnect Case Management at 1-877-590-8999 (TTY: 711), Monday through Friday, 8:30 a.m. to 5 p.m.
- Fax your request to 1-408-874-1957.
- Or make your request by mail:
Attn: Case Management Department
Santa Clara Family Health Plan
PO Box 18880
San Jose, CA 95158
Generally, we pay for drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. We have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan.
We will pay for prescriptions filled at an out-of-network pharmacy in the following cases:
- When filling a specialized drug that is otherwise not available at a network pharmacy
- When filling a drug that has limited distribution
- When filling a drug in an emergency situation when network pharmacies are not available, such as emergency illness while traveling or during a declared disaster
In these cases, please check first with SCFHP Cal MediConnect Customer Service to see if there is a network pharmacy nearby.
You can ask for published materials for free in other formats, such as large print, Braille, or audio. Call SCFHP Cal MediConnect Customer Service for help.
If you speak a language other than English, language assistance services, free of charge, are available to you. Call SCFHP Cal MediConnect Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m. The call is free.