After-hours and emergency care
After-hours
care
You may need to talk to your child’s doctor after his or her
office is closed. Your child’s PCP or another doctor working
with him or her is on call 24 hours a day. Call the PCP’s
office. Your doctor’s answering service will take a message. A
doctor should call you back within an hour. Call again if you do
not hear from a doctor within one hour.
You can also call the Texas
Children’s Health Plan Nurse Help Line to talk to a nurse. The
telephone number is 1-800-686-3831. Nurses are available 24
hours a day, seven days a week to answer your questions. If it
is not an emergency, you can call the Nurse Help Line to find
out how to care for your child at home. Your child will be more
comfortable and you can wait until morning to call the doctor.
Emergency
care
When your child needs emergency care, Texas Children’s Health
Plan covers care at any emergency room in the United States.
Your child is covered for emergency care 24 hours a day, seven
days a week. In an emergency, take your child to the nearest
emergency room for help.
Emergencies include:
- Bleeding that will not stop
- Broken bones
- Loss of consciousness
- Chest pain
- Drug overdose
- Poisoning
- Sudden trouble breathing
After your child receives care,
call his or her doctor as soon as possible. Your child’s PCP will
provide or arrange for any follow-up care. If you get follow-up
care from a doctor other than your child’s PCP without a
referral, Texas Children’s Health Plan may not pay for the care.
If you are sure your child’s
illness or injury is not life threatening but are not sure if he
or she needs emergency care, call your child’s PCP. You can
expect to see his or her PCP on the same day. The PCP will tell
you if you should go to the emergency room. If you feel that
taking time to call the PCP will risk your child’s health, get
help immediately at the nearest emergency room.
You may have to pay if you go to
the emergency room for a condition that is not life threatening.
Urgent
care
When your child has a medical problem that is not an emergency
but requires quick medical attention, this is known as urgent
care. Urgent care includes:
- Earaches
- Cuts and scrapes
- Bruises
- Colds, flu, sore throat,
coughing or sneezing
- Diaper rash
- Low-grade fevers
- Mild vomiting or diarrhea
- Sprains
You must first call your child’s
PCP at the number shown on the front of the ID card. When you
call your child’s PCP, you will be told if you need to take your
child to the emergency room. Many illnesses do not need to be
treated in the emergency room. Expect appointments for urgent
care to be scheduled within 24 hours of your request.
If your child’s PCP tells you to
take your child to the emergency room, you must to go to an
in-network hospital. A list of in-network hospitals can be found
in your CHIP provider
directory.
Care when
you are away from home
Texas Children’s Health Plan covers urgent and emergency care
when your child has a sudden illness or injury anywhere in the
United States. Health care services received outside the United
States are not covered.
If your child is sick or injured
and not in serious danger when you are outside the Texas
Children’s Health Plan service area, call your child’s PCP for
advice. Texas Children’s Health Plan’s service area for CHIP
includes: Austin, Brazoria, Chambers, Fort Bend, Hardin, Harris,
Jasper, Jefferson, Liberty, Matagorda, Montgomery, Newton,
Orange, Polk, San Jacinto, Tyler, Waller, Walker and Wharton
counties.
If your child has an emergency and
you are outside the Texas Children’s Health Plan service area,
go to the nearest emergency room. Call your child’s PCP as soon
as possible.
Your child’s PCP will set up
follow-up care received outside the Texas Children’s Health Plan
service area. If you get follow-up care without a referral,
Texas Children’s Health Plan may not pay for the care.
There is no coverage for routine
care given outside the Texas Children’s Health Plan service
area. Routine care includes:
- Checkups
- Physicals
- Tests
- Non-urgent surgeries
Hospital
services
Your child’s PCP or a specialist may decide that your child
needs care at a hospital. The doctor will arrange for care at a
hospital that is in the Texas Children’s Health Plan network.
Your child is covered for both inpatient and outpatient care.
Your child’s PCP will need to approve these services.
Filing
claims for emergency care
If you receive emergency care from a hospital or doctor not
listed in the Texas Children’s Health Plan
CHIP provider
directory, you may need to file a claim. Keep a copy of the
bill. Call Member Services for instructions on how to file a
claim.
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