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Get Answers To The Most Common Questions About Smart Deductible

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. 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. CDPHP has a national network and can frequently locate a participating provider.

Q. How do I access my out-of-network benefits?

A. Members of the Smart Deductible do not have coverage outside the CDPHP network. Please refer to the benefit materials provided to you at the time of enrollment for specifics on your out-of-pocket costs. These vary according to the plan purchased by your employer group.

Q. Do I have to choose a primary care physician (PCP) to direct my care?

If you have Smart Deductible coverage you do not need to select a PCP. However, we still recommend that you establish yourself with a doctor who will deliver your routine services and coordinate your care with specialists. Office visits to this doctor will not be subject to the deductible so you will always pay your coinsurance or copay. Please use Find-A-Doc to view the range of doctors available within the CDPHP network.

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 and a claim form 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.