How to Choose & See a Provider
How to Choose & See a Provider
When you join SCFHP Cal MediConnect, one of the first things to do is choose a doctor. The doctor you choose will be your primary care provider (PCP). You can choose any PCP who is in our network and 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. This is called prior authorization. See Chapter 3 of your Member Handbook for information about referrals and Chapter 4 of your Member Handbook for information about what services need prior authorization.
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.
To request a hard copy of the Provider and Pharmacy Directory in the mail, please click here to submit an online request, or call Customer Service at 1-877-723-4795, Monday through Friday, 8 a.m. to 8 p.m. TTY/TDD users should call 1-800-735-2929 or 711. The call is free.
NOTE: SCFHP contracts with many providers throughout Santa Clara County. Some SCFHP Cal MediConnect network providers may have been added or removed from our network after this directory was printed. To get the most up-to-date information about SCFHP Cal MediConnect providers in your area, call Customer Service at 1-877-723-4795, Monday through Friday, 8 a.m. to 8 p.m. TTY/TDD users should call 1-800-735-2929 or 711. The call is free.
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 currently 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.
You may be able to have a specialist act as your PCP. A specialist is a doctor who provides health care services for a specific disease or part of the body. You may choose a specialist as your PCP if that doctor is listed as a PCP in the Provider and Pharmacy Directory. You may also choose a Clinic as your PCP, including a Federally Qualified Health Center (FQHC), Community Clinic or an Indian Health Service Facility.
You may receive care from a nurse practitioner (NP), physician assistant (PA) or certified nurse midwife (CNM) to provide your PCP services. The NP, PA, or CNM must work in your PCP’s office and be supervised by your PCP. If you are pregnant or you are planning to become pregnant, you also have the right to select an out-of-plan CNM.
A downloadable copy of the Provider and Pharmacy Directory is available in the Resources section on the right side of this page. Or go to Member Materials to view or download the 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 Customer Service at 1-877-723-4795, Monday through Friday, 8 a.m. to 8 p.m. TTY/TDD users should call 1-800-735-2929 or 711. This call is free.
- If you have questions about whether we will pay for any medical service or care that you want or need, call Customer Service—before you get the service or care
You may change your PCP for any reason, at any time. Also, it’s possible that your PCP may leave our network. If your PCP leaves our network, we can help you find a new PCP who is within our network.
If we can make the change you want, the change to your new PCP will, in most cases, be effective the first day of the next month. For example, if you ask to change PCP in February, in most cases, you will be able to visit your new PCP on March 1.
Talk to your Care Coordinator for assistance or call Customer Service at 1-877-723-4795. TTY/TDD users should call 1-800-735-2929 or 711.
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 referrals for some types of services, or for certain prescriptions drugs, your PCP may need to get approval in advance from our plan. This is called getting prior authorization.
It is important to know which providers are part of our network because, with limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when you are out of the area), out-of-area dialysis services, during declared disasters, and cases in which SCFHP Cal MediConnect Plan authorizes use of out-of-network providers.
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 the request for prior authorization 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.
You may be able to get Long-Term Services and Supports (LTSS) as an SCFHP Cal MediConnect member. LTSS are help for people who need assistance to do everyday tasks like taking a bath, getting dressed, making food, and taking medicine. Most of these services are provided at your home or in your community but could be provided in a nursing facility or hospital.
These services include Community-Based Adult Services (CBAS), Multipurpose Senior Services Program (MSSP), and long-term care (LTC) in a nursing facility.
- CBAS: To apply for CBAS or MSSP, please contact Customer Service at 1-877-723-4795. TTY/TDD users should call 1-800-735-2929 or 711.
- Skilled Nursing Facilities: Use our Find a Doctor search or see the Provider and Pharmacy Directory for contracted Skilled Nursing Facilities. Contact your PCP or SCFHP Customer Service for assistance with long-term care placement.
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.
- 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.
- If you are in a skilled nursing facility, you can remain at that facility. You do not need to move.
- Please 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 in your SCFHP Member Handbook for more information on getting care.
To request continuity of care:
- Call Customer Service at 1-877-723-4795, Monday through Friday, 8 a.m. to 8 p.m. TTY/TDD users should call 1-800-735-2929 or 711.
- You may also submit your request by fax at 1-408-874-1957
- You may also make your request by mail:
Attn: Case Management
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 source by law
- 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 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 Customer Service for help.
If you speak a language other than English, language assistance services, free of charge, are available to you. Call Customer Service at 1-877-723-4795, Monday through Friday, 8 a.m. to 8 p.m. TTY/TDD users should call 1-800-735-2929 or 711. The call is free.
(8:00 a.m. - 8:00 p.m.
Monday - Friday)
Santa Clara Family Health Plan Cal MediConnect Plan (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees.
Enrollment in Santa Clara Family Health Plan Cal MediConnect Plan (Medicare-Medicaid Plan) depends on contract renewal. CMS (the Centers for Medicare & Medicaid Services) must approve SCFHP Cal MediConnect each year. You can continue to get health coverage as a member of our plan only as long as we continue to offer the SCFHP Cal MediConnect Plan for the year in question and CMS renews its approval of the plan. Even if SCFHP leaves the program, you will not lose health coverage. If SCFHP decides not to continue for the next calendar year, we must send you a letter at least 90 days before your coverage will end. The letter will explain your options for Medicare coverage in your area.
Last updated 12/28/2018