Community First Health Plans, San Antonio’s only local, non-profit health plan provider, celebrates its 30th anniversary this year! Since its founding in 1995, Community First has touched over 3.5 million lives, providing access to quality health care and giving back to the families and communities we serve.
Over the past three decades, our commitment to improving the health and well-being of our Members and community as a whole has only strengthened and grown. It has been our great honor and privilege to serve our fellow San Antonians, as we strive for health equity, fewer obstacles to getting needed care, and better health outcomes for all.
STRENGTH IN NETWORK
We would not be where we are today without a dedicated network of Providers. Thanks to your expertise and compassion, you've made a difference in the lives of many.
And as the health care industry continues to evolve, we appreciate your ability to evolve with it, improving patient engagement, practicing trauma-informed care, and digging deeper to resolve health inequalities and improve non-medical drivers of health and obstacles to needed care.
We value your partnership and recognize your ongoing contributions to uplift our community and build a healthier South Texas.
STRENGTH IN COMMUNITY
As part of our vision and mission, we invest in local charitable organizations across Bexar County and beyond that provide resources and care for the underserved, and families in need outside of a doctor's office or hospital setting. By providing funding that other non-profits need to continue their meaningful work that so many rely on, we are creating a ripple effect, leading to a healthier future.
Through our work with these organizations, under the strong and innovative leadership of CEO and President Theresa Rodriguez Scepanksi, we have helped to expand access to preventive care, mental health services, and chronic disease management within our service area. The community initiatives she has led include installing more than 50 food pantries locally, launching educational scholarship programs, and partnering with organizations to provide safe spaces, educational resources, and basic needs to those in our community.
A native San Antonian, Scepanski explains, "Growing up on the south side of San Antonio and experiencing firsthand the challenges many families face, I have always felt the pull to give back to the community that raised me. It is a privilege to lead Community First and to work alongside other outstanding leaders who are equally dedicated to transforming health care for the underserved."
STRENGTH IN COMMITMENT
Over the past three decades, Community First has grown and evolved, working tirelessly to provide high-quality health coverage to those who need it most. From the beginning, our mission has centered on empowering individuals and families to lead healthier lives. We have witnessed that mission come to life through countless success stories from our Members and others in our community.
We pledge to continue building on the strong foundation we have established over these past 30 years and to continue investing in strategies that foster collaboration, reduce administrative burden, and improve efficiency for our Providers.
PROVIDER TIP SHEET
HEDIS® Cervical Cancer Screening (CCS)
Coding
Tip Sheet for Providers
As part of Community First's ongoing efforts to improve care and ensure compliance with HEDIS® measures, we want to remind our network of Providers about the importance of accurate coding and documentation for Cervical Cancer Screening (CCS)
This measure tracks the percentage of women aged 21–64 who were screened for cervical cancer according to established guidelines. Accurate coding and documentation are essential for meeting HEDIS® requirements and ensuring proper reimbursement.
Who To Screen
Clinical practice guidelines recommend women aged 21–64 who have been screened for cervical cancer with a Pap smear or HPV test during the measurement year or in the previous years as per the guidelines.
Recommended Screening Guidelines
• Ages 21–29: Pap smear every 3 years.
• Ages 30–64: Pap smear every 3 years, or Pap smear combined with an HPV test every 5 years.
• For women who have had a hysterectomy with removal of the cervix, screening is not required unless they have a history of cervical cancer or high-grade pre-cancerous lesions.
CPT and ICD-10 Codes
Use the following CPT codes and ICD-10 diagnosis codes for accurate billing and reporting:
To ensure accurate reporting, correct reimbursement, and compliance, here are some common billing errors to avoid:
• Incorrect Age Group: Screening should be conducted for women aged 21–64.
• Failure to Document Screening: Be sure to document all screenings, distinguish between Pap smears and HPV tests, and note the appropriate test method used.
• Incorrect Diagnosis Code: Use Z12.4 for cervical cancer screenings and appropriate codes for routine exams.
• Lack of Documentation for Co-testing: If both a Pap smear and HPV test are performed, ensure both tests are documented and corresponding codes are included.
Conclusion
Cervical cancer was one of the most common causes of cancer death for American women. Effective screening and early detection of cervical pre-cancers have led to a significant reduction in this death rate.1 Accurate coding ensures compliance with HEDIS® measures, proper reimbursement, and improved health outcomes for the women under your care. We appreciate your continued efforts to provide high-quality care to your patients. By following these guidelines and using the correct codes, we can achieve better health outcomes and meet HEDIS® standards for cervical cancer screening.
References:
1. American Cancer Society. 2020. “Key Statistics for Cervical Cancer.” Cancer.org/Cancer/ Cervical-Cancer/About/Key-Statistics.html Last modified July 30.
HEDIS® Chlamydia Screening in Women (CHL)
Coding Tip Sheet for Providers
As part of Community First's ongoing efforts to improve care and ensure compliance with HEDIS® measures, we want to remind our network of Providers about the importance of accurate coding and documentation for Chlamydia Screening in Women (CHL)
This measure tracks the percentage of sexually active women aged 16-24 who were screened for chlamydia during the measurement year. Accurate coding and documentation are essential for meeting HEDIS® requirements and ensuring proper reimbursement.
Who To Screen
Clinical practice guidelines recommend routine chlamydia screening for (1) women aged 16-24 who are sexually active or (2) women who have been dispensed prescription contraceptives during the measurement year.
Annual screening is recommended for all sexually active women under 25 and those with risk factors such as multiple partners or a history of sexually transmitted infections (STI).
Testing Method
Ensure you document the method of testing (e.g., urine test, swab sample) and the associated CPT code for accurate reporting.
The following CPT codes are used for chlamydia screening and are essential for accurate billing:
87110 87491
87320 87490
87810 87492 87270
Common Billing Errors
To ensure accurate reporting, correct reimbursement, and compliance, here are some common billing errors to avoid:
• Incorrect Age Group: Screening should be conducted for women aged 16-24 and older women with identified risk factors.
• Incorrect Diagnosis Code: Use Z11.3 for screening and Z00.00 or Z00.01 for routine exams.
• Failure to Document: Always document sexual activity/risk factors to justify need for screening.
Conclusion
Chlamydia is the most commonly reported bacterial sexually transmitted disease in the United States. It occurs most often among adolescent and young adult females.1,2 Untreated chlamydia infections can lead to serious and irreversible complications. This includes pelvic inflammatory disease (PID), infertility, and increased risk of becoming infected with HIV. Screening is important, as approximately 75% of chlamydia infections in women and 95% of infections in men are asymptomatic. This results in delayed medical care and treatment.3
By adhering to these guidelines and using the correct codes, we can ensure better health outcomes and HEDIS® compliance.
References:
1. Centers for Disease Control and Prevention (CDC). 2014. “Sexually Transmitted Diseases: Chlamydia—CDC Fact Sheet. CDC.gov/STD/ Chlamydia/STDFact-Chlamydia-Detailed.html
2. National Chlamydia Coalition. 2010. “Research Briefs: Developments in STD Screening: Chlamydia Testing.” 2010 Series, No. 1.
3. Meyers, D.S., H. Halvorson, S. Luckhaupt. 2007. “Screening for Chlamydial Infection: An Evidence Update for the U.S. Preventive Services Task Force.” Ann Intern Med 147(2):135–42.
HEDIS® Diabetic Measures at a Glance
HEDIS® Diabetic Measures at a Glance
With support from their health care providers, patients can manage their diabetes properly. Please use this Provider Tip Sheet to review Healthcare Effectiveness Data and Information Set (HEDIS) diabetic measures, coding tips, and best practice recommendations.
Eligible Population
Patients 18-75 years old with diabetes (Type 1 or Type 2) with either of the following during the measurement year or the year prior to the measurement year:
• Encounter Data: Has at least two diagnoses of diabetes on different dates of service.
• Pharmacy Data: Has at least one diagnosis of diabetes and has had any of these hypoglycemic or antihyperglycemic diabetes medications dispensed:
Blood Pressure Control for Patients with Diabetes (BPD)
This measure looks at the percentage of Members 18 to 75 years of age with diabetes (type 1 and 2) whose blood pressure (BP) was adequately controlled (<140/90 mm Hg) during the measurement year.
Systolic Blood Pressure
CPT-CAT II:
3074F, systolic <130mmHg
3075F, systolic 130-139mmHg
3077F, systolic ≥140mmHg
Diastolic Blood Pressure
CPT-CAT II:
3078F, diastolic <80 mmHg
3079F, diastolic 80-89 mmHg
3080F, diastolic ≥ 90 mmHg
Use CPT Category II codes when billing BP completed in the clinic or if BP was obtained during a telehealth visit.
Document BP Readings
• Take BP and record it in the patient’s medical record at every office visit, telehealth visit, e-visit, or other virtual check-in.
• Encourage patients to use a digital device to track and report their BP values. If the reading is captured with a digital device, patient-reported data is acceptable to document in the medical record.
• Ranges and thresholds do not meet the criteria for this measure. A distinct numeric result for both the systolic and diastolic BP readings is required.
HEDIS Measure
Blood Pressure Control for Patients with Diabetes (BPD), continued
Coding Tips
• Confirm that CPT Category II codes listed on the superbill or within the Electronic Health Record (EHR) are valid.
• Consider adding a $0.01 charge when using CPT Category II codes to ensure they are not rejected on the encounter or claim.
Recommendations
• Instruct office staff to recheck BP for all patients with initial recorded readings greater than systolic 139 mm Hg and diastolic of 89 mm Hg during outpatient office visits. Staff should record the recheck in the patient’s medical record.
• Select the appropriately sized BP cuff and place cuff on bare arm.
• Help the patient get a digital monitoring machine for home use and educate them on how to use it.
• Allow the patient to rest for at least five minutes before taking the BP reading.
• Review the patient’s hypertensive medication history and patient compliance and consider modifying treatment plans for uncontrolled BP, as needed. If the patient’s BP is out of control, refer the patient for pharmacy and/or Case Management services.
• Educate patients about the risks of uncontrolled blood pressure and reinforce the importance of adhering to their medication program.
• Refer high-risk Community First patients to our hypertension programs for additional education and support.
PROVIDER TIP SHEET
HEDIS Measure
Eye Exam for Patients with Diabetes (EED)
This measure looks at screening or monitoring for diabetic retinal disease as identified by administrative data. This includes diabetics who have had one of the following:
• A retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) in the measurement year.
• A negative retinal or dilated eye exam (negative for retinopathy) by an eye care professional in the year prior to the measurement year.
• Bilateral eye enucleation at any time during the patient’s history through December 31 of the measurement year.
• When you receive results from an optometrist or ophthalmologist, submit them on a $0.01 claim with an appropriate CPT code (2022F or 2023F).
• If a primary care provider’s office has equipment to complete retinal imaging with interpretation by artificial intelligence (AI) in their office, the practitioner can report completion of the eye exam by submitting a claim with CPT code 92229 for the services provided and the appropriate CPT II code to report the exam results.
Recommendations
1. Frequency of Eye Exams:
• Annual dilated or retinal eye exams are required for patients with positive retinopathy.
• Patients without evidence of retinopathy should have these exams every two years
• Document the date of service, eye exam results, and the eye care professional’s name with credentials.
2. Documentation Requirements:
• Patient-reported eye exams are acceptable, but they must include the required documentation (date, results, eye care professional’s name, and their credentials).
• If the name of the eye care professional is unknown, document that the exam was conducted by an optometrist or ophthalmologist.
• Evidence of prosthetic eye(s) is acceptable for enucleation. Even with unilateral enucleation, the remaining eye still requires an annual exam.
3. Educational Responsibilities:
• Explain to patients the difference between a routine eye exam (for glasses, glaucoma, or cataracts) and a dilated/retinal exam required for diabetic screening.
• Emphasize the importance of routine screenings and compliance with medications.
HEDIS® Diabetic Measures at a Glance
HEDIS Measure
Kidney Evaluation (KED)
The percentage of patients from ages 18–85 with diabetes (type 1 and type 2) who received both of the following:
• A kidney health evaluation defined by an estimated glomerular filtration rate (eGFR)
• A urine albumincreatinine ratio (uACR) during the measurement year.
Glycemic Status Assessment for Patients with Diabetes (GSD)
The GSD measure assesses the percentage of patients from ages 18-75 with diabetes (type 1 and 2) whose most recent glycemic status (hemoglobin A1C [HbA1c] or glucose management indicator [GMI]) was at the following levels during the measurement year:
• Glycemic Status <8.0%
• Glycemic Status >9.0%
A lower rate indicates better performance.
Coding Tips
CPT estimated glomerular filtration rate (eGFR)
80047, 80048, 80050, 80053, 80069, 82565
albumin test
CPT
CPT II
83036, 83037
3044F, 3046F, 3051F, 3052F
Recommendations
• Lab test reports should indicate that both an eGFR and uACR were performed during the measurement year on the same or different dates of service.
• Order labs to be completed prior to patient appointments.
• Ensure labs are ordered at least annually, preferably at the beginning of the year.
• When ordering the urine test, be sure that the albumin and creatinine values are being measured and reported and that both codes are being billed (82043, 82570).
If your practice uses Electronic Medical Records (EMRs), set up flags or reminders in the system to alert your staff when a patient’s screenings are due.
• Send appointment reminders and call patients to remind them of upcoming appointments and necessary screenings.
• Follow up on lab test results and document them.
• Draw labs in your office if accessible or refer patients to a local lab for screenings.
Remember to include the applicable category II reporting code on the claim form to help reduce the burden of HEDIS medical record reviews.
If using an EMR system, consider electronic data sharing with Community First to capture all coded elements. Contact your Community First Provider Relations representative or call 210-358-6294 for reimbursement information.
Communicating to Improve Continuity of Care
Continuity of care is the consistent and seamless provision of ongoing health care management to a patient over time, ensuring coordinated and high-quality treatment across various Providers and settings. Creating a system in which the patient’s core team of Providers can become familiar with the patient’s health history and needs over time is critical to improving patient experience and achieving better health outcomes. Such a system requires clear, consistent, and comprehensive communication between Primary Care Providers (PCPs), Specialists, and other Health Care Providers.
Central to continuity of care is a focus on the whole patient, prioritizing their specific needs, building trust, and nurturing understanding between the patient and their various treating Providers.
Please use these tips for enhanced communication to collaborate, document, and communicate treatment effectively and clearly.
TIPS FOR ENHANCED COMMUNICATION AMONG PROVIDERS
Release of Information
Share Accurate Contact Information
• Obtain a release of information signed by the patient to contact their PCP, Specialist, or other Provider.
• Document in the patient’s chart when you release information to other Providers.
• Communicate with office staff to find out the best means to communicate and share information with other Providers.
• Ensure that contact information on referrals or other shared information includes the most effective/timely means to reach you
TIPS FOR ENHANCED COMMUNICATION AMONG PROVIDERS,
Develop a Working Relationship
Joint Patient Consultations
Set up a Standard Procedure
• Ask the PCP’s office if they have a treatment summary form that they can share. If you are a PCP, make this information readily available.
• If you are a Specialist or other Provider, create a treatment summary form and share it with the PCP to better coordinate care when the Member attends their medical appointments.
• Discuss and coordinate an established protocol between the PCP, Specialist, and other Providers for urgent medical needs.
• Keep the patient aware of the content of communications as clinically appropriate.
• When necessary, consult with the patient, PCP, and Specialists online, on the phone, or in person. This includes regular Specialist attendance at Primary Care team rounds to provide consistent and seamless care for the patient.
• Strive to make communication with all of your patients’ Providers a normal part of doing business.
• Routinely communicate with other Providers at specific points in treatment, such as:
» At initiation of services.
» When significant changes in treatment or patient status occur.
» When preparing for discharge.
» After discharge.
• Integrate PCP communication into the Individual Service Plan (ISP), if applicable.
• Use a form for communication between the PCP and Specialist, including Behavioral Health Providers.
• Talk to the patient about the benefits of collaborative care including:
» Decrease in hospitalization
» Improved physical health
» Improved mental health
» Fewer interactions between medications
TIPS FOR ENHANCED COMMUNICATION AMONG PROVIDERS,
Shared Electronic Progress Notes
Discuss Patient’s Health Concerns
• Use a Continuity of Care Document or Record (CCR), if possible. A CCR summarizes a patient’s Electronic Health Record (EHR) in a standardized manner. It enables care teams to seamlessly, securely exchange patient information. Along with a Continuity of Care Document (CCD), a CCR facilitates the portability and interoperability of patient data.
• Keep accurate, comprehensive notes on medical care. Share data, including:
» Patient demographics
» Patient history
» Medications
» Allergies
» Procedures
» Encounters
» Problem lists
» Diagnoses
» Lab results
» Immunizations
» Health risk factors
» Non-medical Drivers of Health (NMDOH)
• Ask the patient about their medical condition or any new or lingering health concerns they may have.
• Discuss their health concerns and gauge their understanding of medical conditions, recommendations, or treatments.
• Help the patient come up with relevant questions to ask their other Providers.
• Write down any recommendations on care or “homework” that the patient needs to take care of at home.
SOURCES
Interactive Communication between Primary Care and Specialty Care Improves Patient Outcomes Publication Brief (va.gov)
Foy R, Hempel S, Rubenstein L, Suttorp M, Seelig M, Shanman R, and Shekelle P. Meta-Analysis: Effect of Interactive Communication between Collaborating Primary Care Physicians and Specialists. Annals of Internal Medicine February 16, 2010;152(4):247-58.
Community First uses a Member-Centric Population Health Management (PHM) strategy that allows us to focus on care that addresses each Members’ preferences, needs, and values. The framework of this strategy identifies the needs of our community, stratifies these needs for intervention, and focuses on the transition to value-based care in our contracted network.
The tools in our PHM strategy include the following:
Health Assessments. Health Assessments collect important information about Members, including their health literacy, risks and health behaviors, demographics, values, and special needs. Health Assessments also help us connect with our Members at all stages of life (i.e., early childhood, adolescence, adulthood, and old age), and better understand how they approach conditions and prefer to receive information.
Risk Stratification Risk Stratification arranges Members into meaningful categories for personalized intervention targeting. This includes everyone in our Member population, from low-risk to highrisk. Most health care costs are incurred by a minority of the population so it is important to strategize as to where to target investments that can yield the highest return, both in improved health outcomes and cost reductions.
Enrollment and Engagement. Enrollment and engagement include coordination of care across all settings for every Member. Engaging Members in their health care helps them to appropriately access care and services. Enrollment and engagement include self-determined participation in intervention-directed activities that are in alignment with the Members’ goals.
Person-Centered Interventions. Person-centered clinical and wellness interventions include a broad range of approaches and activities tailored to improve the health and well-being of an individual. These interventions can direct resources toward the areas of greatest population risk and opportunities for health improvement. This includes disease management, medication adherence, lifestyle management, and ongoing behavioral health coaching and education.
Providers play a key role in our overall strategy, including promoting healthy habits and increasing Member engagement in our Health & Wellness Programs. Our current Health & Wellness Programs include:
> ASTHMA MATTERS
Asthma Management Program
> DIABETES IN CONTROL
Diabetes Management Program
> HEALTHY MIND
Behavioral Health Program
> HEALTHY LIVING
Lifestyle Management Program
> HEALTHY EXPECTATIONS
Maternity Program
> HEALTHY HEART
Blood Pressure Management Program
Utilization Management: The Process Behind the Decision
Community First utilizes evidence-based criteria and clinical guidelines to make Utilization Management (UM) decisions. The criteria are applied in a fair, impartial, and consistent manner that serves the best interest of our Members.
Community First approves or denies services based on whether the service is medically needed and a covered benefit. Criteria used to make a determination are available upon request.
Service Review
A service review for authorization will occur before a Member receives care. All requests are reviewed by our experienced clinical staff. Service requests that fall outside of standard criteria and guidelines are reviewed by our physician staff for plan coverage and medical necessity.
If care is received that was not authorized in advance (for emergency services), a service review will occur before the claim is processed. Please note that a service review that happens after (emergency) services are received does not guarantee payment of claims.
Generally, your office staff will request prior authorization from Community First before providing care. You have a responsibility to make sure you are following Community First rules for providing care.
Out-of-Network Care
Requests for out-of-network services involve an evaluation of whether the necessary and covered services can be provided on time by a network Provider. Community First does not cover out-ofnetwork care without prior approval.
Hospital Care
Community First also reviews care our Members receive while in the hospital. We assist hospital staff in making sure our Members have a smooth transition home or to their next care setting.
Appeals
The Member, the Member’s representative, or a physician acting on behalf of the Member may appeal a decision denying a request for services. Members can file an appeal through the Community First appeals process.
More Information
To obtain more information about UM criteria used to make decisions about your patient’s health care, contact Population Health Management. Call 210358-6030 and press “2” for authorizations, Monday through Friday from 8 a.m. to 5 p.m.
Our UM staff is also available to assist you with any questions you may have regarding processing a request for services. Calls or communications received after hours will be addressed by the next business day. Should our staff attempt to reach you, they will provide you with their full name and title at Community First.
COMMUNITY FIRST PROVIDER PORTAL
HOW OUR PORTAL STREAMLINES CLAIMS MANAGEMENT & MORE
Create an account or log in now to begin using the benefits and features of the Community First Provider Portal, a secure resource designed to simplify prior authorization processes, claims management, and increase collaboration and care coordination.
Provider Portal Features:
• Submit claims and claim appeal requests
• Search claims, check status, and view the EOP
• Confirm membership and verify coverage
• Submit authorization requests
• View authorization approvals, denials, and other documents
• Receive Community First and HHSC news alerts
• View the SK-SAI (STAR Kids Screening and Assessment Instrument) for STAR Kids patients
• View the SK-ISP (STAR Kids Individual Service Plan) for STAR Kids patients to stay informed of identified needs
Questions? Portal users can find step-by-step guides and register for additional portal training under the Quick Access menu.
Scan the QR code to log in or register for a free account.
Case Management Services
Case Management is a key component of Community First’s Population Health Management strategy. The Case Management (CM) Program provides comprehensive, personalized Case Management services and goal setting for Members who require a wide variety of resources to manage their health and improve their quality of life.
Community First embraces a holistic approach to managing quality of life by treating every Member as a whole. Using this approach, our interdisciplinary Case Management team relies on experienced professionals from diverse backgrounds including social work, nursing, mental health, home care, and home health. The team provides the Member with resources that can help them get the best care possible by utilizing the right Providers, in the right setting, and in the right time frame.
Community First Case Managers serve as the Member’s primary point of contact. The relationship between the Member and Case Manager must be built on trust to foster mutual respect, and to establish a rapport that facilitates communication among the family, caregivers, and other health care team members.
Our Case Management teams are committed to working with Members, their family, doctors, and other Providers on their health care team, to improve the Member’s overall health and wellness and to obtain all needed services.
Case Management is free, voluntary, and available to any Community First Member.
If you would like to refer a patient who may benefit from Case Management, please email the Community First Case Management referral form to chelp@cfhp.com. A Case Manager will contact the Member to discuss their individual health care needs.
If you would like to learn more about Case Management, please call Community First Population Health Management at 210-358-6050.
The Texas Health and Human Services Commission (HHSC) has announced updates to the rollout of the Provider Enrollment and Management System Plus (PEMS+). Community First is sharing this important information to help Providers prepare for upcoming changes.
TIMELINE UPDATES:
• The transition to the new Master Provider File (MPF) was implemented on May 30, 2025.
• The credentialing functionality in PEMS has been delayed until August 31, 2025.
These two changes were originally planned to launch at the same time, however HHSC will now stagger the rollout to minimize Provider disruption and address known data concerns.
WHAT TO EXPECT:
On May 30, 2025:
• HHSC implemented the new PEMS-based Master Provider File. Community First and other Medicaid health plans began using this updated file to manage Provider information. Providers should confirm their practice locations and other information is correct in PEMS as soon as possible. See our PEMS FAQ for more information on this topic.
• New formats for Provider Network Files (P-files), validations, and response files went into effect on June 6, 2025.
By August 31, 2025:
• PEMS will begin supporting managed care credentialing.
• The rollout will take place in phases, starting with Providers undergoing initial credentialing with dental plans, followed by credentialing and recredentialing with health plans like Community First.
• HHSC will collaborate with MCOs to finalize the staged rollout plan.
WHAT THIS MEANS FOR PROVIDERS:
Providers should continue using the current credentialing and recredentialing processes with Community First. The delay in launching credentialing functionality is intended to give HHSC and stakeholders more time to resolve technical issues and ensure a smoother rollout later this year.
It is important that all Providers ensure their Texas Medicaid enrollment remains current and accurate with TMHP, as this data will feed into the new Master Provider File. Keeping enrollment information up to date will help prevent any interruptions in contracting or claims processing when PEMS is fully implemented.
PEMS RESOURCES:
HHSC TexConnect Notice (PDF)
Provider Credentialing in PEMS Postponed
PEMS FAQ
HEDIS® Childhood Immunizations
To help improve immunization rates among young children and support compliance with HEDIS measures, we are sharing updated guidance and coding tips related to childhood vaccines. The following information outlines required immunizations by age two, appropriate coding, and best practices to support timely and accurate vaccine administration and documentation.
• Document both the name of the vaccine and the date it was administered in the medical record.
• Do not count a vaccination administered prior to 42 days after birth with the exception of the 1st dose of HepB.
• Vaccine not required with history of measles, mumps, rubella, chicken pox, or hepatitis A illness on or before the child’s second birthday.
• Educate parents and caregivers about the importance of timely childhood vaccinations. Recommendation from a health care provider remain the number one reason parents decide to vaccinate.
• During telehealth visits, schedule appointments for next immunizations.
• Distribute Vaccine Information Statements (VIS) (required by law) before each dose of vaccine.
• Address common misconceptions about vaccinations (e.g., now disproven MMR causes autism).
• Get more tips from the CDC on effectively communicating the importance of vaccines to parents.
• Utilize the State’s immunization registry to record Member immunizations.
• Establish a reminder system for patients.
• Review the child’s immunization record before every visit and administer needed vaccines.
• Take advantage of every office visit (including sick visits) to catch up on missing vaccines.
• Utilize the appropriate codes to record compliance and reduce the need for medical record requests.
• Request parents provide dates of vaccines given elsewhere.
• Review the CDC's General Best Practice Guidelines for Immunization
21 90716
MANAGEMENT OF PREECLAMPSIA
Preeclampsia is characterized by new onset of hypertension and proteinuria or hypertension and significant end-organ dysfunction, with or without proteinuria after 20 weeks of gestation or postpartum. In the U.S., hypertensive disorders, including preeclampsia, contribute to 7.4% of pregnancy-related deaths. Mental health issues, such as postpartum depression and post-traumatic stress disorder, can also be associated with preeclampsia.
Best Practices for Preeclampsia Management
Prenatal
> Early Indentification and Risk Assessment: Conduct a thorough risk assessment during the initial prenatal visit, considering medical history, predisposing factors, and Non-Medical Drivers of Health (NMDOH), Identify high- and moderaterisk patients promptly
Risk Factors
High Risk
> Kidney disease
> Diabetes mellitus
> Multifetal gestation
> Chronic high blood pressure
> Previous occurrence of preeclampsia
> Autoimmune conditions, such as lupus
Moderate Risk
> First-tie pregnancy
> Body mass inde (BMI) over 30
> Pregnancy more than 10 years after a previous pregnancy
> Family history of preeclampsia (mother or sister)
> Black race
> Low income
> Age 35 or older
> In Vitro Fertilization (IVF)
> Complication is previous pregnancies, such as having a baby with low birth weight
Treating Preeclampsia
> Regular Monitoring: Educate patients on preeclampsia signs and symptoms. Initiate early and frequent monitoring for high-risk patients, including regular blood pressure checks. Encourage pregnant women to monitor their own blood pressure at home, reporting any readings above 140/90. Emphasize fetal movement selfmonitoring. Stress the importance of regular prenatal care throughout the pregnancy.
> Lifestyle Modification: Empower patients to make lifestyle changes, including dietary modifications, exercise, and adequate sleep.
> Antihypertensive Medication and Low-dose Aspirin Use: Consider antihypertensive therapy for women whose blood pressure is persistently elevated over 150/100 mmHg. Initiate low-dose aspirin use before 16 weeks’ gestation for high-risk patients and patients with two or more moderate risk factors.
> Laboratory Tests: Repeat laboratory tests of biochemical and hematological parameters 2–3 times a week, based on the severity and progression of the disease.
> Customized Prenatal Care Models: Explore models such as group care, telehealth, and Connected Care visits for customized prenatal care.
Postpartum
> Preferentially use NSAIDs over opioid analgesics.
> Continue blood pressure measurement postpartum for all women.
> Prescribe antihypertensive medication if hypertension persists after delivery.
> Schedule a blood pressure check visit 3-10 days postdelivery. For mothers on medications, recommend a return visit in 3 days; for those without medications, suggest a return visit in 7-10 days.
SYMPTOMS NYHA class ≥ II *
Suggestive of Heart Failure:
• Dyspnea
• Mild orthopnea
• Tachypnea
• Asthma unresponsive to therapy
Suggestive of Arrhythmia:
• Palpitations
• Dizzines/syncope
Suggestive of Coronary Artery Disease:
• Chest pain
• Dyspnea
VITAL SIGNS
• Resting HR ≥110 bpm
• Systolic BP ≥140 mm Hg
• RR ≥24
• Oxygen sat 96≤%
Cardiovascular Disease Screening Advisory
Preeclampsia increases the risk of cardiovascular disease, a leading cause of maternal mortality in the U.S. during and after pregnancy. The American College of Obstetricians and Gynecologists (ACOG) recommends screening individuals with clinical indications using the provided algorithm.
RISK FACTORS
• Age ≥40 years
• African American
• Pre-pregnancy obesity (BMI) ≥35)
• Pre-existing diabetes
• Hypertension
• Substance use (nicotine, cocaine, alcohol, methamphetamines)
• History of chemotherapy
PHYSICAL EXAM
ABNORMAL FINDINGS
Hear: Loud murmur or Lung: Basilar crackles
Consultation indicated: MFM and Primary Care/Cardiology
Obtain: EKG and BNP
• Echocardiogram +/- CXR if HF or valve disease is suspected, or if the BNP levels are elevated
• 24 Hour Holter monitor, if arrhythmia suspected
• Referral to cardiologist for possible treadmill echo vs. CTA vs. alternative testing if postpartum
Consider: CXR, CBC, Comprehensive metabolic pro le, Arterial blood gas, Drug screen, TSH, etc. Follow-up within 1 week
Results negative
Signs and symptoms resolved Reassurance and routine follow-up
Results abnormal CVD highly suspected
> These are recommendations from the American College of Obstetricians and Gynecologists for clinical findings to guide more extensive assessment of cardiovascular health.
> Asterisk denotes The NYHA Functional Classification is available at Heart.org/HEARTORG/Conditions/ HeartFailure/AboutHeartFailure/Classes-of-Heart-Failure_UCM_306328_Article.jsp.
> National Partnership for Maternal Safety Consensus Bundle on Severe Hypertension During Pregnancy and the Postpartum Period - The American College of Obstetricians and Gynecologists
> Care Plan for Individuals at Risk for Preeclampsia: Shared Approach to Education, Strategies for Prevention, Surveillance, and Follow-up - American Journal of Obstetrics & Gynecology
> Preeclampsia & Pregnancy - American College of Obstetricians and Gynecologists
PROVIDER
TIP SHEET
HEALTH CARE TRANSITION FROM ADOLESCENCE TO ADULTHOOD
The transition from childhood to adulthood is filled with many changes, including a transition from a pediatric to an adult model of care. According to “Supporting the Health Care Transition From Adolescence to Adulthood in the Medical Home”, a clinical report from the American Academy of Pediatrics, optimal health care is achieved when each person, at every age, receives medically and developmentally appropriate care. The goal of a planned health care transition is to maximize lifelong functioning and well-being for all youth, including those who have special health care needs and those who do not.
The following information was compiled to help Community First Providers guide teen and young adult patients and their parents/guardians/caregivers through a successful Health Care Transition (HCT), preparing them for an adult model of care.
HCT Team
A young adult’s HCT team includes:
> Young adult
> Parents/guardians
> Primary Care Provider
> Specialty Care Providers
> Other Providers or support staff, if appropriate
A Provider’s Role
A HCT focuses on building a teen/young adult’s independent health care skills, including selfadvocacy, which will prepare them for the adult model of care. Providers should also help patients find new adult Providers with experience caring for special health care needs, if applicable.
Pediatricians can offer support to patients and their parents by:
> Encouraging them to choose a new doctor with whom they trust and feel at ease.
> Encouraging them to stay in touch, especially in the beginning stages of the transition.
> Aiding both parent and child in making health care decisions, and until the child feels capable of managing their health themselves, the parent may discuss the possibility of the child granting the parent temporary access to medical records.
> Explaining that the adolescent’s decision to take responsibility for their actions is a normal stage of growing up and that doing so is a sign of maturity.
> Helping parents begin the process of finding a new doctor and transferring the child’s records before the child leaves pediatric care.
Timeline
The age and developmental stage of the adolescent are the main factors determining whether it is time to switch to an adult Health Care Provider.
A well-timed transition from child-to adultoriented health care is unique to each individual and ideally occurs between the ages of 18 and 21 years, is determined with the assistance of a pediatrician, and should begin when the child is 14 or 15 years old.
HEALTH CARE TRANSITION — SKILLS CHECKLIST
Use this Health Care Transition Checklist (HCT) to evaluate your pediatric patient’s skill level in managing their own health care needs. Responses can also help you identify at-risk patients, create a detailed transition plan, effectively communicate with a patient’s new Provider(s), and provide patient education to empower them and their parents/ caregivers during this change. Not all skills listed below apply to all patients. Consider involving Case Managers, Service Coordinators, or Transition Specialists to support HCTs for patients with complex needs. And be sensitive to cultural factors that may impact your patient’s understanding. PLEASE CHECK THE BOX NEXT TO THE ANSWER THAT BEST APPLIES RIGHT NOW.
HEALTH CARE SKILL
Patient can name their disability, learning difference, medical, or mental health diagnosis (e.g., diabetes, depression)
Patient can name 2-3 people who can help them in a medical emergency
Patient prepares questions to ask before a doctor’s visit
Patient asks the doctor’s office for accommodations, as needed
Patient knows how to get to doctor’s office or request transportation
Patient can schedule their own appointments
Patient knows what medication(s) they take, including how much and when
Patient knows how to request refills on medication(s), as needed
Patient can list any allergies
Patient knows where to go to get care depending on their needs (e.g., PCP, specialist, urgent care, therapist/ counselor, ED)
Patient knows where to go to get care depending on their needs (e.g., PCP, specialist, urgent care, therapist/ counselor, ED)
If health insurance coverage will change based on their age, patient is aware of next steps and who to call to get help
Patient knows how to find a new doctor if they age out of care or are unhappy with the care they are receiving
WHAT IS EVV: Who Qualifies & What’s New
What is EVV?
EVV stands for Electronic Visit Verification. EVV is a computer-based system that verifies the occurrence, type, and location of certain authorized Medicaid service visits by electronically documenting the precise time a visit begins and ends.
It is a state and federal requirement that an EVV system must be used when providing the following Medicaid services:
> Medicaid personal care services.
> Medicaid home health care services.
What’s New?
Community First Providers can view EVV updates from Texas Health and Human Services (HHSC) and Community First online at Medicaid. CommunityFirstHealthPlans.com/EVV, in addition to:
> EVV contact information for general inquiries and unlock requests
> Community First and HHSC EVV training and education requirements
> EVV unlock request forms and job aids
EVV Trainings and Education Requirements
> HHSC EVV Training Resources
> TMHP EVV Training
> Community First EVV Provider Training
> Community First LTSS Billing Matrix Training Presentation
PROVIDER UPDATE: MEDICAID
IN-LIEU-OF SERVICES & SETTINGS (ILOS)
In-Lieu-of Services and Settings (ILOS) are services and settings that have been approved by the Texas Health & Human Services Commission (HHSC) to be medically appropriate, clinically appropriate, and cost-effective substitutes for covered services under Texas Medicaid.
Texas Medicaid Providers, in network with managed care programs, can use ILOS as an alternative to traditional Medicaid services or settings. This approach aims to reduce health disparities and address unmet Health-Related Social Needs (HRSNs).
ILOS are only available to Members enrolled in Texas Medicaid programs, including:
• STAR
• STAR+PLUS
• STAR Kids
• Medicare-Medicaid Dual Demonstration
EXAMPLES OF ILOS INCLUDE:
• Partial Hospitalization Program (PHP): A structured outpatient program offering behavioral health services such as group therapy, medication management, and nursing services.
• Intensive Outpatient Program (IOP): An outpatient program focused on structured therapy, educational services, and life skills training.
• Coordinated Specialty Care (CSC): A team-based treatment approach for individuals with newly diagnosed psychosis.
WHAT YOU SHOULD KNOW ABOUT ILOS:
• Request ILOS when appropriate, ensuring the request aligns with the Member’s comprehensive treatment plan. Prior authorization required.
• Engage Members in discussions about ILOS to ensure they understand their options and can make informed decisions.
• ILOS may be limited to Members who meet certain criteria. For example, the ILOS may only be available to people who are a specific age.
• ILOS may be limited in quantity or duration. It may also be limited to a specific setting.
• Members have the right to request or decline these services.
• Maintain documentation of the Member’s choice to receive ILOS and make it available upon request.
ILOS are not a replacement for regular services or treatments covered by Community First. They are services substituted for Medicaid State Plan services or settings, as allowed by Medicaid guidelines.
ILOS BILLING:
Refer to HHSC’s Uniform Managed Care Manual (UMCM), chapter 16.3, for procedure codes for PHP, IOP, and CSC.
Pharmacy
NAVITUS HEALTH SOLUTIONS
Below, you will find important information about Community First Member pharmacy benefits managed by Navitus Health Solutions, including how to find the most recent Preferred Drug List. Please review carefully.
Pharmacy Benefit Program
Community First offers Members prescription drug benefits through our pharmacy benefits partner, Navitus Health Solutions. Take the following steps to log in to the Navitus Provider Portal.
1. Visit Prescribers.Navitus.com
2. Click “Sign In” located on the upper right hand corner of your screen.
3. Enter your NPI number and state.
Once logged in, Providers can access the following information:
> List of covered drugs, also called a formulary, and other information including drug tiers and quantity limits.
> Updates to the formulary.
> Prior authorization forms and clinical criteria used for certain medications.
> Information on how to request a formulary exception.
> List of network and specialty pharmacies.
The Texas Vendor Drug Program publishes a Preferred Drug List (PDL) for Medicaid Members every January and July. This list contains preferred covered medications and requirements for using non-preferred medications.
4. For the most up-to-date version of the Medicaid PDL, please visit Medicaid Pharmacy Prior Authorization and PDL.
5. To obtain a paper copy, please contact Provider Services at 210-358-6030.
USE OF FIRST-LINE PSYCHOSOCIAL CARE FOR CHILDREN AND ADOLESCENTS ON ANTIPSYCHOTICS (APP)
Community First is committed to working with our Providers to improve the quality of care for our Members. This Provider Tip Sheet provides information about a Healthcare Effectiveness Data and Information Set (HEDIS®) measure concerning the importance of utilizing psychosocial interventions for children and adolescents (1-17 years of age) before considering antipsychotic medications.
Our goal is to ensure that safer first-line psychosocial interventions are utilized, and that children and adolescents do not unnecessarily incur the risks associated with antipsychotic medications.
HEDIS® Measure Description
The percentage of children and adolescents ages 1-17 who had a new prescription for an antipsychotic medication and had documentation of psychosocial care as their first-line treatment.
HEDIS® Best Practices
Psychosocial care, which includes behavioral interventions, psychological therapies, and skills training – among others – is the recommended firstline treatment option for children and adolescents diagnosed with non-psychotic conditions such as attention-deficit disorder and disruptive behaviors.
When prescribed, antipsychotic medications should be part of a comprehensive, multi-modal plan for coordinated treatment that includes psychosocial care.
Best practices for this population include the following actions:
> Schedule telehealth appointments for patients who have a new prescription for an antipsychotic medication and document psychosocial care as first-line treatment.
> Regularly review the ongoing need for continued therapy with antipsychotic medication.
> Monitor the patient closely for side effects.
> Establish a baseline and continuously monitor metabolic indices, including blood glucose and cholesterol, to ensure appropriate management of side effects.
> Educate and inform parents/guardians of the increased side effect burden of multiple concurrent antipsychotics on children’s health and the implications for future physical health concerns, including obesity and diabetes.
Exclusions
Exclude patients for whom first-line antipsychotic medications may be clinically appropriate, including those with at least one acute inpatient encounter or two outpatient encounters during the measurement year with a diagnosis of:
> Schizophrenia
> Schizoaffective disorder
> Bipolar disorder
> Psychotic disorder
> Autism
> Other developmental disorders
> Patients in hospice or using hospice services anytime during the measurement year
PSYCHOSOCIAL CARE MEASURE CODES
Provider Quick Reference Guide
COMMUNITY FIRST PROVIDER PORTAL
PHYSICAL AND MAILING ADDRESS
Follow-up Care for Children
Prescribed ADHD Medication
Community First is committed to working with our Providers to improve the quality of care for our Members. This Provider Tip Sheet provides information about follow-up care with children who have been prescribed attention-deficit/hyperactivity disorder (ADHD) medication.
The purpose of this Provider Tip Sheet is to help Providers in our network improve their ADHD Healthcare Effectiveness Data and Information Set (HEDIS) follow-up scores. HEDIS helps to rate health plans based on the quality and timeliness of health care, which are factors that contribute significantly to health outcomes. The National Committee for Quality Assurance (NCQA) creates and administers these evaluations.
The ADHD HEDIS Measure is the percentage of children, ages 6-12 years old, newly prescribed ADHD medication who had at least three follow-up care visits within a 10-month period, one of which was within the first 30 days of when the ADHD medication was first dispensed.
Two rates are reported:
» Initiation Phase: Percentage of patients who had one follow-up visit with a practitioner with prescribing authority within 30 days of when the first ADHD medication was dispensed.
» Continuation and Maintenance Phase: After the end of the Initiation Phase, the percentage of patients who remained on ADHD medication for at least 210 days (7 months) and who had at least two follow-up visits within 270 days (9 months).
Improving Your ADHD HEDIS Follow-Up Scores
1. Initiation Phase: To ensure the patient completes a follow-up visit within 30 days of a new prescription, prescribe no more than a 30-day supply of medication during the first visit. Schedule the first followup visits within 14-21 days to assess the patient’s response to the medication and evaluate for possible adverse effects, OR consider prescribing an initial 14-day supply and subsequent 30-day supplies to ensure adequate patient follow-up. Remember that telephonic and telehealth visits qualify for this measure.
2. Continuation and Maintenance Phase: To ensure that the patient receives at least two additional follow-up visits within nine months (270 days), schedule these appointments while the patient is at the clinic for their first appointment.
» One of two visits may be an e-visit or virtual check-in, depending upon the Member’s benefits.
» Do not continue prescriptions unless the patient completes at least two appointments each year so you can evaluate progress and the effectiveness of the medication.
» Explain to parents/caregivers how to monitor children who receive ADHD medication and why it is important to do so.
Community First recognizes the importance of a three-way relationship among its Members, Providers, and their health plan. Member education about health care responsibilities is important because it helps Members get greater benefits from their plan.
Community First Providers can find Member Rights and Responsibilities listed in each plan’s Community First Provider Manual. Members can find the same list in their plan’s Member Handbook.
For more information about Member Rights and Responsibilities, please contact Community First Provider Services at 210-358-6030.
A PRESCRIPTION FOR WELLNESS
Our Health & Wellness programs were designed to provide guidance to our Members so that they can achieve better health outcomes. A referral to our programs helps us complement your efforts as a caring, engaged Provider. Please review our family of programs.
Asthma Matters
Asthma Management Program
> Education about the causes or triggers of asthma
> Tips to achieve normal or near-normal lung function
> Advice on how to participate in physical activity without symptoms
> Ways to decrease the frequency and severity of flare-ups
Qualifying Members may be eligible for a $10 gift card for completing asthma education, a $10 gift card for receiving a flu shot, and up to $80 in gift cards for completing home visits with San Antonio Kids BREATHE ($35 for the first visit, $10 for the second visit, and $35 for the third visit).*
Diabetes in Control
Diabetes Management Program
> Diabetes education classes
> Information on how to control blood sugar
> Tips for talking to Providers
> Blood sugar testing and supplies
> One-on-one access to a Health Educator
> Referral to YMCA Diabetes Prevention Program including a complimentary four-month YMCA membership
Qualifying Members may be eligible for up to $60 in gift cards for Members with diabetes participating in the Diabetes in Control: Diabetes Management Program (includes a $20 gift card for completing the Community First diabetes assessment, a $10 gift card for completing diabetes educations, a $10 gift card for receiving a dilated eye exam, and a $10 gift card once every six months for submitting A1C results).*
Healthy Expectations Maternity Program
> One-on-one access to a Health Educator
> Prenatal and postpartum education
> Home visits for high-risk pregnancies
> Mommy & Me baby shower with gifts
Qualifying Members may be eligible for a total of $150 in gift cards ($30 each for the following: Community First Health Assessment, agreeing to receive health education text messages, attending all required pre- and postnatal checkups, receiving a flu shot during pregnancy, and attending a Mommy & Me Baby Shower). There is also a $30 reimbursement for birthing classes.*
Healthy Mind
Behavioral Health Program
> Help determining the type of behavioral health assistance needed
> Information to help choose the right professional counselor or doctor
> Case Management for high-risk Members
Healthy Living
Lifestyle Management Program
> One-on-one contact with a Health Educator
> Referral to YMCA Weight Loss Program, including a complimentary 4-month YMCA membership
> Case Management for high-risk Members
> Access to Zumba and other fitness classes at no cost
Healthy Heart
Blood Pressure Management Program
> One-on-one contact with a Health Educator
> Case Management for high-risk Members
Refer a Patient
If you have a patient who could benefit from participating in one or more of our Health & Wellness Programs, we encourage you to contact Population Health Management at 210-358-6055 or email healthyhelp@cfhp.com.
You can also advise the patient to:
> Take our online Health Assessment available on our website at CommunityFirstHealthPlans.com/Healthand-Wellness-Programs, or
> Email healthyhelp@cfhp.com, or
> Call 210-358-6055 to speak with a Health Educator.
All Health & Wellness Programs are provided at no cost, and Members can opt out of a program at any time.
Community First strives to provide the best quality services to our Members. A referral to our family of Health & Wellness programs helps us complement your efforts as a caring, engaged Provider.
* Limitations and restrictions apply. For eligibility requirements, please call 210-358-6055 or email healthyhelp@cfhp.com.
FOLLOW-UP AFTER EMERGENCY DEPARTMENT VISIT FOR MENTAL ILLNESS (FUM) WITHIN 7 DAYS
Why is the FUM HEDIS® Measure important?
Evidence suggests that individuals who receive follow-up care within 7 days after a behavioral health-related Emergency Department (ED) visit have fewer repeat ED visits, improved physical and mental function, and increased compliance with their care plan. Providers should encourage follow-up care after ED visits.
What does the FUM Measure assess?
The FUM Measure assesses the percentage of emergency department (ED) visits for Members six years of age and older with a principal diagnosis of mental illness or any diagnosis of intentional self-harm who had a follow-up visit for mental illness within 7 days of the ED visit.
When does a Member “pass” the measure?
A Member “passes” the measure by attending a mental health follow-up visit with any practitioner (to include PCPs, Pediatricians, and Mental Health Providers) within 7 days.
Which services qualify to meet this measure?
Follow-up visits can be completed by any qualified Provider as long as the claim includes a mental health diagnosis and the Provider is licensed to bill the appropriate codes, such as:
> Telehealth
> Telephone call
> Peer support and residential treatment services
> Intensive outpatient
> Partial hospitalization
> Electroconvulsive therapy
> Outpatient office-based care
> Community mental health center
Best Practice Recommendations
> Offer telehealth and phone visits.
> Submit claims in a timely manner.
> Use appropriate documentation and correct coding.
> Mental health outpatient officebased care
> Online assessment (e-visit or virtual check-in)
> Educate staff on local resources to assist with barriers such as transportation needs.
FOLLOW-UP AFTER EMERGENCY DEPARTMENT VISIT FOR MENTAL ILLNESS,
> Coordinate care between Behavioral Health and Primary Care Providers by sharing progress notes and updates.
> Make reminder calls to Members before scheduled appointments and after any missed appointments to reschedule.
> Review medications with patients to ensure they understand the purpose, appropriate frequency, and method of administration for each prescribed medication.
> Ensure flexibility when scheduling appointments for patients who were recently seen in the ED to allow for appointments to be scheduled within 7 days of discharge.
CPT Codes for Behavioral Health Billing
Visits
BH Outpatient
90791 90792 90832 90833 90834
90836 90837 90838 90839 90840
90845 90847 90849 90853 90875
90876 99221 99222 99223 99231 99232
99233 99238 99239 99251 99252
99253 99254 99255
98960 98961 98962 99078 99201
99202 99203 99204 99205 99211 99212
99213 99214 99215 99241 99242 99243
99244 99245 99341 99342 99343 99344
99345 99347 99348 99349 99350 99381
99382 99383 99384 99385 99386
99387 99391 99392 99393 99394
99395 99396 99397 99401 99402
99403 99404 99411 99412 99483 99492
99493 99494 99510
Partial Hospitalization or Intensive Outpatient N/A
A healthier Member is our goal, and it starts with reliable transportation
Community First now partners with SafeRide Health to improve the Member experience through their transportation benefit program.
Non-emergency medical transportation (NEMT) services ensure Community First STAR, STAR Kids, STAR+PLUS, Medicare Advantage, and Medicare D-SNP Members have reliable transportation to health care appointments, including visits to doctors, dentists, hospitals, pharmacies, and other locations where they get covered services.
Booking Rides:
• Call SafeRide at 855-932-2335 (Monday–Friday, 8:00 a.m. to 6:00 p.m.). Call at least 48 hours before the Member’s appointment.
• Provide Member details: name, Medicaid or Medicare ID number, DOB, height/weight, appointment info, pick-up/drop-off addresses, and preferred modality.
• Discharge reservations/assistance available Monday through Friday, 4 a.m. to 8 p.m.
Available Ride Options:
• Ambulatory door-to-door transportation for patients who can walk while supported by device and need assistance
• Wheelchair/bariatric transportation
SUPPORTING CARE: WORKING TOGETHER TO CONNECT
PHYSICAL AND BEHAVIORAL HEALTH
At Community First, we know how critical Primary Care Providers (PCPs) are in supporting Behavioral Health (BH). You’re often the first point of contact and the connection between a Member’s physical and mental health needs. At the same time, we understand that collaboration isn’t always easy, especially when different Providers use different Electronic Health Record (EHR) systems. That’s why we’re here to help make communication easier and more effective.
WHAT HAPPENS WHEN CARE IS CONNECTED?
• Improved quality of care
• Reduction in health care costs
• Enhanced patient safety
• Greater patient care experience
• Efficient delivery of care
SIMPLE STEPS FOR STRONGER CARE CONNECTIONS
Here are some requirements and tips to facilitate the flow of communication between different health care settings and Providers.
• A release of information form must be on record for information to be shared between the PCP and the BH Provider.
• BH Providers and PCPs are required to send each other initial and updated (quarterly or more frequently, if clinically indicated) summary reports of a Member’s physical and BH status (as agreed to by the PCP team members and with the consent of the Member or the Member’s legal guardian).
• BH Providers are required to refer Members with known or suspected and untreated physical health problems or disorders to their PCP (with the consent of the Member or the Member’s legal guardian).
COMMUNICATION FORM
Community First has developed a standard communication form to help facilitate information sharing between physical and BH Providers.
Our Quality Management clinical staff monitors for the presence of release forms and indication of communication between BH Providers and PCPs during medical record documentation audits.
When PCPs and BH Providers work together, patients receive more consistent, comprehensive support. We’re committed to working alongside you to simplify processes, strengthen connections, and most importantly, help every Member get the care they deserve.
Community First Announces Partnership with
Community First Health Plans, Inc. (Community First) is happy to announce a partnership with Progeny Health, a company which specializes in Neonatal Care Management Services. This is an exciting opportunity. ProgenyHealth’s care management program will enhance services to our Members and support our mission to make a lasting difference in our Members’ lives by improving their health and well-being.
Under the agreement that begins October 1, 2025, ProgenyHealth’s Neonatologists, Pediatricians, and Neonatal Nurse Care Managers will work closely with Community First Members, as well as attending physicians and nurses, to promote healthy outcomes for Community First premature and medically complex newborns.
The benefits of this partnership to you:
• The support of a team who understands the complexity and stress of managing infants in the NICU and will work with you to achieve the best possible outcomes.
• A collaborative and proactive approach to care management that supports timely and safe discharge to home.
• A company that believes in sharing best practices and works with NICUs nationwide to improve the health outcomes of our next generation.
Families will have a dedicated case manager who will give support and education to Members in the program, and access to an “on-call” staff member available 24/7. For our hospitals, ProgenyHealth will serve as a liaison for Community First, providing inpatient review services and assisting with the discharge planning process to ensure a smooth transition to the home setting.
Your process for notifying Community First of infants admitted to a NICU or special care nursery will remain the same. Community First will notify ProgenyHealth of admissions, and their clinical staff will contact your designated staff to perform utilization management and discharge planning throughout the inpatient stay.
If you wish to learn more about ProgenyHealth’s programs and services, visit progenyhealth.com. Thank you for your partnership in caring for Community First Members.
Resources:
ProgenyHealth Neonatal Care Management – FAQ
ProgenyHealth NICU Care Management – Flyer
Neonatal Care Management
Frequently Asked Questions (FAQ)
Who is ProgenyHealth?
ProgenyHealth is the only national company dedicated to the care management for NICU infants.
Our Care Coordination Team includes neonatologists, pediatricians, lactation consultants, nurses, and social workers with a deep understanding of the latest evidence-based protocols needed to improve outcomes for premature and medically complex newborns and solve for the social determinants of health.
What activities will ProgenyHealth conduct?
ProgenyHealth’s clinical care nurses conduct admission and continued stay review, discharge planning, and post hospitalization care of newborns admitted to the NICU or Special Care Nursery. These services
Our Case Management department consists of nurse case managers, social workers, and case management associates who deliver our comprehensive services telephonically. This team outreaches to families during the inpatient stay, discusses case management needs, and collaborates with hospital discharge planners and hospital social workers to safely transition from the hospital to home. ProgenyHealth’s Case Managers
What are ProgenyHealth’s hours of operation?
ProgenyHealth’s regular hours of operation are 8:30 a.m. to 5:00 p.m. Monday through Friday EST. However, our hours of operation may var y based on health plans that are located outside of the Eastern Standard Time zone. Our dedicated care managers work flexible hours to make themselves available to you.
How do I contact ProgenyHealth for admission and continued stay review of newborns?
You will notify ProgenyHealth or the Health Plan via phone, fax, or provider portal, depending on the health plan. ProgenyHealth will guide you with regard to this process. For continued stay review, you may contact ProgenyHealth directly:
Utilization Management: Call 888-832-2006 and select option 3
Utilization Management Secure Fax Number: This dedicated fax number will be provided by ProgenyHealth
Case Management: Call 888-832-2006 and select option 4
Case Management Secure Fax Number: 855-834-2567
Non-Discrimination Notice Aviso sobre no discriminación
Community First Health Plans, Inc. and Community First Insurance Plans (Community First) comply with applicable federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, sex, gender identity, or sexual orientation. Community First does not exclude people or treat them differently because of race, color, national origin, age, disability, sex, gender identity, or sexual orientation.
Community First provides free aids and services to people with disabilities to communicate effectively with our organization, such as:
Qualified sign language interpreters
Written information in other formats (large print, audio, accessible electronic formats, and other formats)
Community First also provides free language services to people whose primary language is not English, such as:
Qualified interpreters
Information written in other languages
If you need these services, please contact Community First Member Services at the number on the back of your Member ID card or 1-800-434-2347. If you’re deaf or hard of hearing, please call 711.
If you feel that Community First failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, sex, gender identity, or sexual orientation, you can file a complaint with Community First by phone, fax, or email at:
Community First Compliance Coordinator
Phone: 210-227-2347 | TTY: 711 Fax: 210-358-6014
Email: DL_CFHP_Regulatory@cfhp.com
If you need help filing a complaint, Community First is available to help you. If you wish to file a complaint regarding claims, eligibility, or authorization, please contact Community First Member Services at 1-800-434-2347.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf.
You may also file a complaint by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201
Phone: 1-800-368-1019 | TTY: 1-800-537-7697
Complaint forms are available at: https://www.hhs.gov/civil-rights/filing-a-complaint/complaintprocess/index.html
Community First Health Plans, Inc. (Community First) y Community First Insurance Plans cumplen con las leyes federales de derechos civiles aplicables y no discriminan por motivos de raza, color, nacionalidad, edad, discapacidad, sexo, identidad de género, u orientación sexual. Community First no excluye o trata de manera diferente a las personas debido a su raza, color, nacionalidad, edad, discapacidad, sexo, identidad de género, u orientación sexual.
Community First proporciona asistencia y servicios gratuitos a personas con discapacidades para comunicarse efectivamente con nuestra organización, como:
Intérpretes calificados de lenguaje de señas Información escrita en otros formatos (letra grande, audio, formatos electrónicos accesibles, y otros formatos)
Community First también ofrece servicios gratuitos lingüísticos a personas cuyo idioma principal no es el inglés, como:
Intérpretes calificados
Información escrita en otros idiomas
Si usted necesita recibir estos servicios, comuníquese al Departamento de Servicios para Miembros de Community First al 1-800-434-2347. TTY (para personas con problemas auditivos) al 711.
Si usted cree que Community First no proporcionó servicios lingüísticos gratuitos o se siente que fue discriminado/a de otra manera por motivos de su raza, color, nacionalidad, edad, discapacidad, sexo, identidad de género, u orientación sexual, usted puede comunicarse con Community First por teléfono, fax, o correo electrónico a:
Community First Compliance Coordinator
Teléfono: 210-227-2347 | Línea de TTY gratuita: 711 Fax: 210-358-6014
Correo electrónico: DL_CFHP_Regulatory@cfhp.com
Si usted necesita ayuda para presentar una queja, Community First está disponible para ayudarlo. Si usted desea presentar una queja sobre reclamos, elegibilidad o autorización, comuníquese con Servicios para Miembros de Community First llamando al 1-800-434-2347.
Usted también puede presentar una queja de derechos civiles ante el departamento de salud y servicios humanos de los Estados Unidos de manera electrónica a través del portal de quejas de derechos civiles, disponible en: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf También puede presentar una queja por correo o por teléfono al:
KOREAN: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-434-2347 (TTY: 711)번으로 전화해 주십시오.
ARABIC: رق م 1-800-434-2347
(TTY: 711)
TAGALOG: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-434-2347 (TTY: 711).
FRENCH: ATTENTION: Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le 1-800-434-2347 (ATS: 711).
HINDI
PERSIAN
(TTY: 711)
(TTY: 711)
GERMAN: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-434-2347 (TTY: 711).
As we celebrate our 30th anniversary, we honor our deep-rooted commitment to the health and well-being of our local community. Thank you for your trust and for allowing us to serve you and your loved ones all these years. Together we look forward to building a healthier future for all of us.
