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Specialty Care and Referrals

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.

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 careOb/GYN care
  • Behavioral Health or Drug and Alcohol Treatment
  • Routine Vision
  • Family Planning

If you have questions or need help finding a provider for these services, you can call Member Services at 800-964-2247.

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.

For more information about prior authorizations, click here.

Second Opinions

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.