Children's Health Insurance Program appeals

The Children’s Health Insurance Program (CHIP) is health coverage for children. How your child’s denial is reviewed depends on whether the coverage is a separate CHIP program or is part of Medicaid. This page is mainly about the separate programs. The reference page is Children’s Health Insurance Program.

What this means

If your child gets CHIP through an expansion of the state Medicaid program, the Medicaid rules in Medicaid appeals and fair hearings are the usual rules. That is the standard reading, but this site has not checked it against regulation text. Ask your state agency which kind of coverage your child has.

For a separate CHIP, a state chooses one of two models. It may run a “program specific review” that meets federal rules, or use a “statewide standard review” that follows the state’s review rules for all health insurers.

The matters that must be reviewable are:

• Eligibility and enrollment. A denial of eligibility, a failure to decide eligibility on time, and a suspension or end of enrollment, including for unpaid cost sharing.
• Health services. A delay, denial, reduction, suspension or end of services, and a failure to approve, provide or pay for services on time.

For health services, your child must have access to an independent external review, conducted by the state or by a contractor other than the one responsible for the decision.

What to do

1. Read the notice (you). A CHIP notice must be timely and in writing, and give the reasons, the right to review, the standard and fast timeframes, how to ask for review, and when enrollment and benefits may continue. The deadline to ask is in the notice. This site has not confirmed one federal request deadline.
2. Find out if your child is in a plan or the state program (you). If a managed care plan made the decision, it must follow most of the Medicaid plan appeal rules: one level of plan appeal, 60 calendar days to file, 30 calendar days to decide a standard appeal and 72 hours for a fast one.
3. File the review or appeal (you). Follow the notice. If your child’s doctor says waiting could seriously harm your child’s health, tell the reviewer that. A fast review is decided within 72 hours when the physician or plan says the standard time could seriously jeopardize life, health or the ability to function. If there are two levels, 72 hours applies to each.
4. Ask for the external review (you). For health services, it must be completed within 90 calendar days of the request for internal or external review, covering both levels. After a plan appeal, the state external review must be available for no less than 90 and no more than 120 calendar days from the plan’s decision.
5. Keep copies and write down every call (you). See keep a call log.

Check the date on your notice, which controls.

What the federal rules do not guarantee

Federal CHIP rules require enrollment and benefits to continue during review only for the suspension or end of enrollment and for a failure to decide eligibility on time. They do not require a disputed service to continue while the review runs, and they do not require a Medicaid-style fair hearing. Your state may give more. Check your notice and your state’s page.

Prior authorization times

From 1 January 2026, CHIP prior authorization has a 7 calendar day standard deadline and a 72 hour fast deadline, with a possible extension of up to 14 days. Drugs are not covered by that rule.

The rule

For health services matters, the enrollee must have access to an independent external review, conducted by the state or by a contractor other than the one responsible for the decision. (Title 42 of the Code of Federal Regulations (CFR), section 457.1150(b))

Watch for

• “CHIP works just like Medicaid.” It does not. Separate CHIP programs use external review instead of a fair hearing and are not required by federal rules to continue a disputed service.
• A special children’s standard. The special rule that requires Medicaid to cover medically necessary services for people under 21, known as Early and Periodic Screening, Diagnostic and Treatment, is a Medicaid rule. This site has not confirmed that it applies to a separate CHIP.
• State rules. States run CHIP differently. Your state page lists the agency and deadlines it records.

What next

• Medicaid appeals and fair hearings covers the Medicaid route.
• Medicaid managed care: the plan appeal comes first explains plan appeals, which CHIP plans largely follow.
• State consumer advocates lists free help in your state.