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HMO FAQs

Get answers to our most common questions about HMO plans.

Q. How do I change my primary care physician (PCP) or OB/GYN?

A. You can change your PCP or OB/GYN through the Secure Member Site using your member ID and password. If you need help choosing a physician, please contact the CDPHP Member Services Department or use our Find-A-Doc tool.

Q. What should I do if I have an emergency when I’m out of the area?

A. A medical emergency is defined as a sudden illness or injury so severe that the average person would believe that immediate medical attention is needed to avoid serious health damage or bodily harm.

If you have an emergency outside the CDPHP service area, go to the nearest hospital emergency room. CDPHP will cover the hospital emergency room bill in full — minus your copayment. See Out-of-Area coverage (NEED LINK) for details. If the situation is urgent but not an emergency, such as a sore throat, sprain, or infection, contact the CDPHP Resource Coordination Department at 1-800-274-2332 for advice in obtaining the care you need.

Q. How do I submit a claim?

A. If you’ve received a covered service and the provider of medical services requested that you pay the charge at the time of service, send a completely itemized bill to our office so that you receive the maximum available benefits. That bill should include:

  • Provider’s name, address, telephone number, and tax ID number
  • Date of service
  • Name of each procedure/procedure code, including the name of any drugs
  • Charge for each procedure
  • Diagnosis
  • Receipt for any payment made
  • Member’s name and ID number

Please send claim to: Capital District Physicians’ Health Plan, Inc., P.O. Box 66602, Albany, NY 12206-6602.

Note: this same process applies to claims for care you received out of the country.

Q. Can I order my prescription drugs by mail?

A. Yes. The CDPHP Mail Order Prescription service is available to members who have a prescription drug rider and who take maintenance medication.

Q. Do I need a referral to see a specialist?

A. Yes, you should contact your PCP before making any appointments for specialty care (other than OB/GYN, routine eye care, and dental visits).