How to choose a provider and get care

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 DualConnect, including:

• X-rays
• Laboratory tests
• Therapies
• 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 use our online Find a Doctor tool to find a PCP in the SCFHP DualConnect 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 DualConnect Plan 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 DualConnect Plan Customer Service at 1-877-723-4795 (TTY: 711), 7 days a week, 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.

To request changing your PCP, log in to mySCFHP or call SCFHP DualConnect Plan Customer Service at 1-877-723-4795 (TTY: 711), 7 days a week, 8 a.m. to 8 p.m.

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 DualConnect member ID card with the name of your new PCP on it. Once you get your new SCFHP DualConnect ID card, we ask that you destroy your old SCFHP DualConnect 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. Refer to Chapter 4 of the SCFHP DualConnect Member Handbook for more information on which services require prior authorization. Find the SCFHP DualConnect 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 DualConnect Customer Service at 1-877-723-4795 (TTY: 711), 7 days a week, 8 a.m. to 8 p.m.

If medically necessary specialized services are not available from a provider in the SCFHP DualConnect 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), refer to Chapter 3, Section D of your SCFHP DualConnect Member Handbook. Find the SCFHP DualConnect Plan 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
• 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 DualConnect Case Management at 1-877-590-8999 (TTY: 711), Monday through Friday, 8:30 a.m. to 5 p.m.

If SCFHP DualConnect 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 SCFHP to continue to use 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 DualConnect.
  
  • 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, transportation, other ancillary services, or services not included under SCFHP DualConnect.

After the continuity of care period ends, you will need to see doctors and other providers in the SCFHP DualConnect network unless we make an agreement with your out-of-network doctor. A network provider is a provider who works with the health plan. Refer to Chapter 3, Section B of the SCFHP DualConnect Member Handbook in Member Materials for more information on getting care.

To request continuity of care:

• Call SCFHP DualConnect 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 DualConnect 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 DualConnect Customer Service for help.

If you are more comfortable speaking a language other than English, SCFHP can help you. Whether you are contacting SCFHP or visiting a doctor, we have interpreters available. Tell your doctor you would like an interpreter for your visit.

Know your rights

• You can get an in-person or telephone interpreter at no cost to you. This includes American Sign Language.
• When you go to the doctor, interpreters are available 24-hours a day.
• You can ask for SCFHP DualConnect materials written in other languages.

How can you get an interpreter?

Tell your doctor’s office you would like one. You can do this when you call to set up your next visit. You can also ask us for an interpreter or for translated materials.