Specialty Care and Referrals
Cook Children's Health Plan (CCHP) is aware that managed care is a new model of care for STAR Kids members and families, and CCHP is committed to a "continuity of care" process. As such CCHP will respect relationships that STAR Kids members have developed over time with their physicians. This means that all physicians who are currently providing services, both primary and speciality services, will continue to be accessible to STAR Kids members without need for authorizations.
In operating the continuity of care process, Cook Children's Health Plan does not require referral or authorization to in-network specialists, including behavioral health care. While Members may seek specialist services from in-network providers without Cook Children's Health Plan approval, we do encourage Members to engage their primary care provider (PCP) and medical home first, to ensure that the specialist is the right one for the illness or condition, that the specialist does not require information from the primary care provider, and that the information from the visit is communicated back to the PCP.
From November 1, 2016 through October 31, 2017, Cook Children's Health Plan will not require referral or authorization to an out-of-network specialist either in or out of the service area if the member has an established relationship with the specialist. Please note that an out-of-network physician must be a valid Medicaid provider to receive payment for services from Cook Children's Health Plan and the services must be Medicaid covered services. Below are specific examples:
(1) If the Member is seeking services from a new specialist with no existing relationship, CCHP does not require referral or authorization for an in-network specialist. We may require an authorization for some services that the specialist may perform, such as allergy or psychological testing.
(2) If the Member is seeking urgent care from a new specialist, CCHP does not require referral or authorization for an in-network specialist. We do encourage Members to contact their primary care provider first, to make sure it is appropriate to wait, monitor that the illness does not turn into an emergency, and facilitate the appointment.
If a Member is seeking emergency services from a new specialist, CCHP does not require referral or authorization if the services are needed to evaluate or stabilize the emergency medical condition and are performed by a provider that is qualified to furnish the emergency services.
(3) If the Member is seeking services from a specialist with an existing relationship, as noted above from November 1, 2016 through October 31, 2017, CCHP will not require referral or authorization to an out-of-network specialist either in or out of the service area if the member has an established relationship with a specialist. We may require authorization for some services that the specialist may perform, such as allergy or psychological testing. Note that out-of-network physicians must be Medicaid providers to receive payment for services and the services must be Medicaid covered services.
Accessing Care - Specialty Care
What if I need to see a special doctor (specialist)?
Your Primary Care Provider or attending specialist may request that a specialist see you or perform special tests. If you think you may need to see a specialist doctor, we encourage you to discuss this with your Primary Care Provider or attending specialist.
What is a referral?
Your Primary Care Provider or attending specialist can help arrange for you to see a new specialist. This is called a "referral".
If you have a specialist who already takes care of you then a referral is not needed. If your specialist is contracted with Cook Children's Health Plan, then no authorization is needed for specialist visits. An authorization is needed for out of network specialists to help with claims payment. Your service coordinator can also help you with access to specialists.
How soon can I expect to be seen by a specialist?
After getting a referral from your Primary Care Provider or attending specialist, you should be able to see the new specialist within 3 weeks for a routine appointment or within 24 hours for urgent care appointments.
If you need help with this, please contact your Primary Care Provider, your attending specialist, or your service coordinator.
What services do not need a referral?
There are certain services you can get without a referral from your Primary Care Provider or Cook Children's Health Plan. These services include:
- Specialists, in network, who currently provide care
- Emergency care Routine Vision
- Behavioral Health or Drug and Alcohol Treatment
- OB/GYN care
- Family Planning
Accessing Care - Authorizations
What is an authorization?
Some health care services require a review by Cook Children's Health Plan before you can get them. This is called a prior authorization. The provider must send a request and information about how the services will help you.
Cook Children's Health Plan has three (3) working days to make a decision for routine requests. We will make a decision sooner if there is an urgent need.
A Service Coordinator is available to help answer any questions you may have about this.
How can I ask for a second opinion?
The doctor might tell you that you have a disease or need to have an operation. You have the right to have another doctor look at you and give you his or her opinion. If you want a second opinion, tell your primary care provider.
If you think that you want another doctor to see you and give you his or her opinion, we will pay for that visit.