Rady Children's Health Network

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Frequently Asked Questions

How do I contact my doctor after hours or on weekends? 

Call your doctor’s office first, anytime, day or night. Your doctor or nurse will give you medical advice and, if needed, send you to the right place to receive the care your child needs. 

Which Urgent Care should I go to? 

If your doctor says to take your child to Urgent Care, you have many options that your insurance covers. You can easily find a nearby Urgent Care location by looking it up here. 

How do I know if a doctor is in network? 

Ask your pediatrician first. You can also search by doctor name or specialty on our “Find a Doctor” page. 

How do I find a speech, occupational or physical therapy provider?

Finding a therapy provider can be easy. Here’s how you can find help for speech, occupational, or physical therapy:

  • School District Services: You can get FREE therapy services through your school district. Just contact them for more information.
  • Rady Children’s Hospital Services: Rady Children’s Hospital San Diego offers pediatric therapy services in many locations.
What if I want a second opinion? 

If you want a second opinion, you’ll need to request authorization (approval) through your health plan. Just call the member services number on your insurance card for help. 

What is an Authorization and how does the authorization process work? 

RCHN wants your child to get the best care as quickly as possible. We only ask for authorizations when it’s really needed.

When Authorization is Needed:
If your child needs a medical service that requires authorization, the doctor will send a request to Rady Children’s Health Network (RCHN).

How the Process Works:
RCHN’s clinical staff will review the request. You and your doctor will get a letter in the mail with the decision.

Notification of Decision:
The letter will tell you if the service is approved or denied. If approved, it will include details like the type of service, the number of services, and the name of the provider.

Appealing a Denial:
If the service is denied, you can appeal the decision with your health plan. The letter will explain how to do this.

Additional Information:
You can ask RCHN for any policies or criteria used to make the decision. If you have questions about the process or your request, please contact us at 1-877-276-4543.

Example: Imagine your child needs to see a specialist for a skin condition. The regular doctor sends a request to RCHN. RCHN reviews it and sends you a letter saying the visit is approved. The letter will tell you the specialist’s name and how many visits are approved. If it’s not approved, the letter will explain how you can appeal the decision.

What services require prior authorization? 

Some medical services need approval before your child can get them. Here are the services that require prior authorization:

  • Acupuncture
  • Chiropractic Care
  • Cochlear Implants and Supplies
  • CT Scans (only for headaches)
  • Dental Anesthesia
  • Durable Medical Equipment (DME)
  • Genetic Testing
  • Hearing Aids and Supplies
  • Home Health Services
  • Infusion Therapy
  • Injectable Medications
  • Inpatient Admissions (staying in the hospital)
  • MRI Scans (only for headaches)
  • Nutrition/Weight Management
  • Occupational Therapy
  • Orthotics/Prosthetics (braces and artificial limbs)
  • Out of Network Services (services from providers not in the network)
  • PET Scans
  • Physical Therapy
  • Speech Therapy
  • Transplants

If you have any questions about these services or need help with the authorization process, please contact us at (877) 276-4543.

How is an authorization decision made? 

When your child needs a medical service, sometimes we need to approve it first. This is called an authorization.

What We Look At:
We make our decision based on a few things.

  • Medical Information: We review the medical details your doctor provides.
  • Insurance Coverage: We check what your health insurance plan covers.
  • Medical Policies: We follow the rules and guidelines of your health plan.
  • Provider Network: We see if the service is available within the Rady Children’s Health Network of providers. 

Important Note: We want you to know that our decisions are based on whether the care being requested is a proven treatment and is medically necessary, and what your health insurance covers. The people who review the authorization requests are not paid extra for denying care or making it difficult to get services. They also don’t receive rewards for unfairly limiting care.

More Information: If you want to see our Affirmative Statement, you can find it by clicking here.