We Pay Attention to Your Child’s Care

Keystone First – CHIP’s licensed doctors and nurses monitor the services given to all Enrollees. They also make decisions about medically necessary care and services. They make these decisions using:

• Nationally accepted clinical guidelines approved by the Department of Human Services
• All of the medical information they are aware of
• Your child’s CHIP benefits
• Your child’s personal medical needs

Keystone First – CHIP does not reward health care providers for denying, limiting, or delaying benefits or health care services. We also do not give incentives to our staff making decisions about medically necessary services or benefits to provide less health care coverage and services. You may ask for a copy of the clinical guidelines used by Keystone First – CHIP by calling Enrollee Services.

Dedication to quality care

Keystone First – CHIP is always looking for new ways to improve your child’s health and to serve you and your child better. We look at new treatments and new technologies to see if they will be helpful to you and your family. We also send information to our providers to help them make decisions about your child’s care. These guidelines are taken from national and regional health care associations and task forces and medical research.

For the services they give, most PCPs get a set dollar amount each month for each Enrollee who chooses that PCP. This pays for most of the services your child gets from their PCP. PCPs are paid extra for some services, like shots (immunizations). When PCPs meet other quality, service, and performance standards set by Keystone First – CHIP, they can also get additional payments.

Keystone First – CHIP also has arrangements with hospitals and doctor groups for certain kinds of services. Sometimes a global fee is paid to cover such services, whether given by the hospital, doctor group, or other providers.

Providers in the Keystone First – CHIP network are encouraged to give quality care to your child. We monitor if the health care and services are being used in the right way, and if they are appropriate and needed. We have Enrollee satisfaction surveys every year and give Enrollee education on health-related issues. If you believe your child got care that was not appropriate, please call Enrollee Services. Keystone First – CHIP will investigate the issue. If you would like more information about our quality improvement goals, activities, or outcomes, please call Enrollee Services.

Find out more
You can find out more about our utilization management process. Please review the Enrollee handbook or call Enrollee Services.