Overview

Benefits and services

How to choose TCHP

Frequently asked questions

After hours

STAR Babies

Your rights and responsibilities

Fraud and abuse

Important phone numbers

Member handbook

STAR provider directory Harris service area

STAR provider directory Jefferson service area

Pharmacy directory

Find a doctor

After-hours care
You may need to talk to your child’s doctor after his or her office is closed. Your child’s PCP or another doctor working with him or her is on call 24 hours a day. Call the PCP’s office. Your doctor’s answering service will take a message. A doctor should call you back within an hour. Call again if you do not hear from a doctor within one hour.

You can also call the Texas Children’s Health Plan Nurse Help Line to talk to a nurse. The telephone number is 1-800-686-3831. Nurses are available 24 hours a day, seven days a week to answer your questions. If it is not an emergency, you can call the Nurse Help Line to find out how to care for your child at home. Your child will be more comfortable and you can wait until morning to call the doctor.

Emergency care
When your child needs emergency care, Texas Children’s Health Plan covers care at any emergency room in the United States. Your child is covered for emergency care 24 hours a day, seven days a week. In an emergency, take your child to the nearest emergency room for help.

Emergencies include:

• Bleeding that will not stop
• Broken bones
• Loss of consciousness
• Chest pain
• Drug overdose
• Poisoning
• Sudden trouble breathing

After your child receives care, call his or her doctor as soon as possible. Your child’s PCP will provide or arrange for any follow-up care. If you get follow-up care from a doctor other than your child’s PCP without a referral, Texas Children’s Health Plan may not pay for the care.

If you are sure your child’s illness or injury is not life threatening but are not sure if he or she needs emergency care, call your child’s PCP. You can expect to see his or her PCP on the same day. The PCP will tell you if you should go to the emergency room. If you feel that taking time to call the PCP will risk your child’s health, get help immediately at the nearest emergency room.

You may have to pay if you go to the emergency room for a condition that is not life threatening.

Urgent care
When your child has a medical problem that is not an emergency but requires quick medical attention, this is known as urgent care. Urgent care includes:

• Earaches
• Cuts and scrapes
• Colds, flu, sore throat, coughing or sneezing
• A severe diaper rash
• Low-grade fevers
• Repeated vomiting or diarrhea
• Sprains

You must first call your child’s PCP at the number shown on the front of the ID card. When you call your child’s PCP, you will be told if you need to take your child to the emergency room. Many illnesses do not need to be treated in the emergency room. Expect appointments for urgent care to be scheduled within 24 hours of your request.

If your child’s PCP tells you to take your child to the emergency room, you must to go to an in-network hospital. A list of in-network hospitals can be found in your STAR Provider Directory for both Harris and Jefferson service delivery areas.

Care when you are away from home
Texas Children’s Health Plan covers urgent and emergency care when your child has a sudden illness or injury anywhere in the United States. Health care services received outside the United States are not covered.

If your child is sick or injured and not in serious danger when you are outside the Texas Children’s Health Plan service area, call your child’s PCP or the Nurse Help Line at 1-800-686-3831 for advice. Texas Children’s Health Plan’s service area for STAR includes: Brazoria, Fort Bend, Galveston, Harris, Montgomery and Waller counties.

If your child has an emergency and you are outside the Texas Children’s Health Plan service area, go to the nearest emergency room. Call your child’s PCP as soon as possible.

Your child’s PCP will set up follow-up care received outside the Texas Children’s Health Plan service area. If you get follow-up care without a referral, Texas Children’s Health Plan may not pay for the care.

There is no coverage for routine care given outside the Texas Children’s Health Plan service area. Routine care includes:

• Checkups
• Physicals
• Tests
• Non-urgent surgeries

Hospital services
Your child’s PCP or a specialist may decide that your child needs care at a hospital. The doctor will arrange for care at a hospital that is in the Texas Children’s Health Plan network. Your child is covered for both inpatient and outpatient care. Your child’s PCP will need to approve these services.

Filing claims for emergency care
If you receive emergency care from a hospital or doctor not listed in the Texas Children’s Health Plan STAR Provider directory, you may need to file a claim. Keep a copy of the bill. Call Member Services for instructions on how to file a claim.