Referrals
Self-referrals
Self-referrals are services you arrange for your child and do not require that your child’s primary care provider (PCP) arrange for your child to receive the services. Your child must use a Keystone First – CHIP network provider unless Keystone First – CHIP approves an out-of-network provider. Services that do not need a referral include:
- Prenatal visits
- Routine obstetric (OB) care
- Routine gynecological (GYN) care
- Routine family planning services (may see out-of-network provider)
- Routine dental services
- Routine eye exams
- Emergency services
Your child may need a referral or prior authorization from their PCP for some specialty care services. There may also be some limitations for self-referrals. If you are not sure if your child needs a referral from their PCP for a service, ask your child’s PCP or call Enrollee Services.
Your child does not need to be referred by their PCP for behavioral health services.
PCP referrals
If your child needs specialized care that their PCP cannot offer, your child can see any in-network specialist you choose without a referral. A specialist is a doctor who is trained and practices in a specific area of medicine (for example, a cardiologist or a surgeon). If your child sees an in-network specialist, it will be covered. Certain co-pays may apply.
There are some treatments and services that your child’s specialist must ask Keystone First – CHIP to approve before your child can get them. Your child’s specialist will tell you what those services are. If you have trouble getting your child the specialist care you think they need, contact Keystone First – CHIP’s Enrollee Services at 1-844-472-2447 (TTY 711).
If Keystone First – CHIP does not have a specialist or other provider in our provider network who can give your child the care they need, we will refer your child to a specialist or other provider outside our plan. This is called an out-of-network referral. Your child’s PCP or another network provider must ask us for approval before your child can get an out-of-network referral. You can talk to your child’s PCP about this or call Keystone First – CHIP’s Enrollee Services at 1-844-472-2447 (TTY 711) to discuss your child’s needs and to get more details. Sometimes we may not approve an out-of-network referral for a specific treatment. This may happen if you ask for care for your child that is like what you can get from a Keystone First - CHIP provider. If you do not agree with our decision, you can appeal our decision.
If your child has a complex health condition or a special health care need, you may be able to choose a specialist to act as your child’s PCP. To learn more or ask to choose a specialist as your child’s PCP, call Keystone First – CHIP’s Enrollee Services at 1-844-472-2447 (TTY 711). We will work with you to help coordinate the care your child needs. No referrals are required for an Enrollee to access care at participating specialists. You are encouraged to work through your child’s PCP for coordination of healthcare needs.