Are specialists covered under CHIP in Utah?
Can my child see a specialist under CHIP, and are referrals required?
Yes, your child can see a specialist under the Children’s Health Insurance Program (CHIP) in Utah. CHIP provides coverage for visits to specialists when necessary to diagnose or treat specific medical conditions. However, depending on the plan and the type of specialist, a referral from your child’s primary care provider (PCP) may be required. Here's what you need to know about seeing a specialist and the referral process under CHIP.
1. Specialist Care Coverage Under CHIP
CHIP in Utah covers visits to a variety of specialists to address specific medical issues, including but not limited to:
Cardiologists for heart conditions.
Endocrinologists for diabetes or hormone disorders.
Pediatric specialists for specific child-related conditions.
Dermatologists for skin conditions.
Orthopedic specialists for bone or joint issues.
Mental health specialists for emotional or behavioral health concerns.
These services are covered as long as the specialist is within the CHIP network and the visit is deemed medically necessary.
2. Are Referrals Required to See a Specialist?
In most cases, you will need a referral from your child’s primary care provider (PCP) before seeing a specialist. This is to ensure that the specialist visit is necessary and covered by CHIP. The referral process typically works as follows:
A. Referral Process
Visit your child’s primary care provider (PCP): Your child's PCP will assess the condition and determine if specialist care is needed.
Request a referral: If the PCP believes your child requires specialized care, they will issue a referral to an in-network specialist.
Submit the referral: Your PCP or you may need to submit the referral to CHIP, depending on your child’s plan, for approval before the specialist visit.
Schedule the appointment: Once the referral is approved, you can schedule an appointment with the specialist. Make sure to verify that the specialist accepts CHIP.
B. When Referrals Are Not Required
In some cases, certain CHIP plans may allow direct access to specialists without a referral, such as for behavioral health services or emergency care. It’s important to check with your CHIP provider for the specific requirements of your child’s plan.
3. How to Find an In-Network Specialist
To ensure that the specialist visit is covered under CHIP, you must select an in-network specialist. Here’s how to find one:
Use the provider directory: Check the Utah Medicaid provider directory or the specific CHIP network directory to find specialists who accept CHIP.
Ask your PCP: Your child’s primary care provider can help you find an appropriate specialist within the CHIP network.
Contact CHIP customer service: You can call the CHIP program to confirm if a particular specialist is in-network.
4. What to Do If a Specialist Visit Is Denied
If your referral for a specialist visit is denied, you have options:
Request an appeal: You can appeal the decision by submitting additional medical documentation from your child’s primary care provider to demonstrate the need for specialist care.
Seek prior authorization: In some cases, you may need to request prior authorization for the specialist visit if it is considered outside the standard CHIP coverage.
Key Takeaways:
CHIP in Utah covers visits to specialists, but a referral from your child’s primary care provider is often required to ensure the visit is covered.
Make sure the specialist is in-network to avoid extra costs, and follow the referral process to obtain approval before scheduling the appointment.
For certain services, like emergency care or mental health services, referrals may not be required.
For assistance finding an in-network specialist or understanding the referral process, schedule an appointment with a Tsunami Advisor here: Schedule an Appointment.
