2013 Organization Determination, Appeals, and Grievances

Organizational Determination (Coverage Decision)

Organizational determination is the process by which the plan makes a decision about whether a service provided for you is covered and the amount, if any, you are required to pay. You, your physician, or your representative may make an oral or written, standard or expedited request.

If you are a Keystone 65 HMO member, you can request an organizational determination by using one of the methods below.

  • Call 1-800-ASK-BLUE (1-800-275-2583).
    Calls to this number are free, 7 days a week, 8 a.m. to 8 p.m. However, please be aware that on weekends and holidays from February 15 to September 30, your call may be sent to voicemail.
  • TTY/TTD 1-888-857-4816.
  • Fax 1-888-289-3008.
  • Write Keystone 65 HMO
    Clinical Precertification
    1901 Market Street
    30th Floor
    Philadelphia, PA 19101-3652

If you are a Personal Choice 65SM PPO member, you can file an organizational determination by using one of the methods below.

  • Call 1-800-ASK-BLUE (1-800-275-2583).
    Calls to this number are free. 7 days a week, 8 a.m. to 8 p.m. However, please be aware that on weekends and holidays from February 15 to September 30, your call may be sent to voicemail.
  • TTY/TTD 1-888-857-4816.
  • Fax 1-888-289-3008.
  • Write Personal Choice 65 PPO
    Clinical Precertification
    1901 Market Street
    30th Floor
    Philadelphia, PA 19101-3652

Organizational Determination Instructions

Download 2013 Organizational Determination Instructions

For more information on Keystone 65 Select Medical-only HMO’s organizational determination process, please reference Chapter 7, Section 4 on page 93 in your EOC or click on the link below.

PDF icon Keystone 65 Select Medical-only HMO Organizational Determination Instructions
Y0041_H3952_KS_13_3026 Accepted 09/12/2012

For more information on Keystone 65 Preferred Medical-only HMO’s organizational determination process, please reference Chapter 7, Section 4 on page 92 in your EOC or click on the link below.

PDF icon Keystone 65 Preferred Medical-only HMO Organizational Determination Instructions
Y0041_H3952_KS_13_3029 Accepted 09/12/2012

For more information on Keystone 65 Select Rx HMO’s organizational determination process, please reference Chapter 9, Section 4 on page 141 in your EOC or click on the link below.

PDF icon Keystone 65 Select Rx HMO Organizational Determination Instructions
Y0041_H3952_KS_13_3027 Accepted 09/12/2012

For more information on Keystone 65 Preferred Rx HMO’s organizational determination process, please reference Chapter 9, Section 4 on page 138 in your EOC or click on the link below.

PDF icon Keystone 65 Preferred Rx HMO Organizational Determination Instructions
Y0041_H3952_KS_13_3028 Accepted 09/12/2012

For more information on Personal Choice 65SM Medical-only PPO’s organizational determination process, please reference Chapter 7, Section 4 on page 91 in your EOC or click on the link below.

PDF icon Personal Choice 65 Medical-only PPO Organizational Determination Instructions
Y0041_H3909_PC_13_2862 Accepted 09/11/2012

For more information on Personal Choice 65SM Rx PPO’s organizational determination process, please reference Chapter 9, Section 4 on page 143 in your EOC or click on the link below.

PDF icon Personal Choice 65 Rx PPO Organizational Determination Instructions
Y0041_H3909_PC_13_2861 Accepted 09/12/2012

Prior Authorization

For Keystone 65 Select and Preferred HMO members, the plan requires prior authorization (approval in advance) of certain covered medical services. Some in-network medical services are covered only if your doctor or other network provider gets prior authorization from the plan. Your in-network provider can request a medical prior authorization on your behalf.

For more information on Keystone 65 Select Medical-Only HMO’s prior authorization process and what services require prior authorization, please reference Chapter 4, Section 2 on page 40 in your EOC or click on the link below.

PDF icon Keystone 65 Select Medical-Only HMO Prior Authorization and Benefits Chart

For more information on Keystone 65 Preferred Medical-Only HMO’s prior authorization process and what services require prior authorization, please reference Chapter 4, Section 2 on page 40 in your EOC or click on the link below.

PDF icon Keystone 65 Preferred Medical-Only HMO Prior Authorization and Benefits Chart

For more information on Keystone 65 Select Rx HMO’s prior authorization process and what services require prior authorization, please reference Chapter 4, Section 2 on page 48 in your EOC or click on the link below.

PDF icon Keystone 65 Select Rx HMO Prior Authorization and Benefits Chart

For more information on Keystone 65 Preferred Rx HMO’s prior authorization process and what services require prior authorization, please reference Chapter 4, Section 2 on page 48 in your EOC or click on the link below.

PDF icon Keystone 65 Preferred Rx HMO Prior Authorization and Benefits Chart

For Personal Choice 65SM PPO members, the plan requires prior authorization (approval in advance) of certain covered medical services. In the network portion of a PPO, some in-network medical services are covered only if your doctor or other network provider gets prior authorization from our plan. In a PPO, you do not need prior authorization to obtain out-of-network services, but you can ask the plan to make a coverage decision in advance.

For more information on Personal Choice 65SM Medical-Only PPO’s prior authorization process and what services require prior authorization, please reference Chapter 4, Section 2 on page 38 in your EOC or click on the link below.

PDF icon Personal Choice 65 Medical-Only PPO Prior Authorization and Benefits Chart

For more information on Personal Choice 65SM Rx PPO’s prior authorization process and what services require prior authorization, please reference Chapter 4, Section 2 on page 47 in your EOC or click on the link below.

PDF icon Personal Choice 65 Rx PPO Prior Authorization and Benefits Chart

Your in-network provider can request a medical prior authorization on your behalf. For more information, click here.

Appeals

If you, your doctor, or your representative do not agree with the outcome of the initial coverage determination, appeal the decision by requesting a redetermination. Learn more about the medical appeals process by reviewing your Evidence of Coverage (EOC).

If you are a Keystone 65 HMO member, you can file a standard or expedited medical appeal by using one of the methods below.

  • Call 1-800-645-3965.
    Calls to this number are free. 7 days a week, 8 a.m. to 8 p.m. However, please be aware that on weekends and holidays from February 15 to September 30, your call may be sent to voicemail.
  • TTY/TTD 1-888-857-4816.
  • Fax 1-888-289-3008.
  • Write Keystone 65 HMO
    Medicare Member Appeals Unit
    PO Box 13652
    Philadelphia, PA 19101-3652

If you are a Personal Choice 65SM PPO member, you can file a standard or expedited medical appeal by using one of the methods below.

  • Call 1-800-718-3333.
    Calls to this number are free. 7 days a week, 8 a.m. to 8 p.m. However, please be aware that on weekends and holidays from February 15 to September 30, your call may be sent to voicemail.
  • TTY/TTD 1-888-857-4816.
  • Fax 1-888-289-3008.
  • Write Personal Choice 65 PPO
    Medicare Member Appeals Unit
    PO Box 13652
    Philadelphia, PA 19101-3652

Download 2013 Medical Appeals Information

For more information on Keystone 65 Select Medical-only HMO Medical Appeals, please reference Chapter 7, Section 4 on page 93 in your EOC or click on the link below.

PDF icon Keystone 65 Select Medical-only HMO Medical Appeals
Y0041_H3952_KS_13_3026 Accepted 09/12/2012

For more information on Keystone 65 Select Rx HMO Medical Appeals, please reference Chapter 9, Section 4 on page 141 in your EOC or click on the link below.

PDF icon Keystone 65 Rx HMO Medical Appeals
Y0041_H3952_KS_13_3027 Accepted 09/12/2012

For more information on Keystone 65 Preferred Medical-only HMO Medical Appeals, please reference Chapter 7, Section 4 on page 92 in your EOC or click on the link below.

PDF icon Keystone 65 Preferred Medical-only HMO Medical Appeals
Y0041_H3952_KS_13_3029 Accepted 09/12/2012

For more information on Keystone 65 Preferred Rx HMO Medical Appeals, please reference Chapter 9, Section 4 on page 138 in your EOC or click on the link below.

PDF icon Keystone 65 Preferred Rx HMO Medical Appeals
Y0041_H3952_KS_13_3028 Accepted 09/12/2012

For more information on Personal Choice 65SM Medical-only PPO Medical Appeals, please reference Chapter 7, Section 4 on page 91 in your EOC or click on the link below.

PDF icon Personal Choice 65 Medical-only PPO Medical Appeals
Y0041_H3909_PC12_01 File & Use 09/15/2011

For more information on Personal Choice 65SM Rx PPO Medical Appeals, please reference Chapter 9, Section 5 on page 145 in your EOC or click on the link below.

PDF icon Personal Choice 65 Rx PPO Medical Appeals
Y0041_H3909_PC12_02 File & Use 09/15/2011

Grievances

You may file a medical grievance if you have a complaint other than one that involves a coverage determination (see Appeals above). You would file a medical grievance for any type of problem you might have with us or one of our network providers.

If you are a Keystone 65 HMO Member, you can file a standard or expedited medical grievance by using one of the methods below.

  • Call 1-800-645-3965.
    Calls to this number are free. 7 days a week, 8 a.m. to 8 p.m. However, please be aware that on weekends and holidays from February 15 to September 30, your call may be sent to voicemail.
  • TTY/TTD 1-888-857-4816.
  • Fax 1-888-289-3008.
  • Write Keystone 65 HMO
    Medicare Member Appeals Unit
    PO Box 13652
    Philadelphia, PA 19101-3652

If you are a Personal Choice 65SM PPO Member, you can file a standard or expedited medical grievance by using one of the methods below.

  • Call 1-888-718-3333.
    Calls to this number are free. 7 days a week, 8 a.m. to 8 p.m. However, please be aware that on weekends and holidays from February 15 to September 30, your call may be sent to voicemail.
  • TTY/TTD 1-888-857-4816.
  • Fax 1-888-289-3008.
  • Write Personal Choice 65 PPO
    Medicare Member Appeals Unit
    PO Box 13652
    Philadelphia, PA 19101-3652

Download 2013 Medical Grievances Information

For more information on Keystone 65 Select Medical-only HMO Medical Grievances, please reference Chapter 7, Section 9 on page 125 in your EOC or click on the link below.

PDF icon Keystone 65 Select Medical-only HMO Medical Grievances
Y0041_H3952_KS_13_3026 Accepted 09/12/2012

For more information on Keystone 65 Select Rx HMO Medical Grievances, please reference Chapter 9, Section 10 on page 185 in your EOC or click on the link below.

PDF icon Keystone 65 Select Rx HMO Medical Grievances
Y0041_H3952_KS_13_3027 Accepted 09/12/2012

For more information on Keystone 65 Preferred Medical-only HMO Medical Grievances, please reference Chapter 7, Section 9 on page 124 in your EOC or click on the link below.

PDF icon Keystone 65 Preferred Medical-only HMO Medical Grievances
Y0041_H3952_KS_13_3029 Accepted 09/12/2012

For more information on Keystone 65 Preferred Rx HMO Medical Grievances, please reference Chapter 9, Section 10 on page 182 in your EOC or click on the link below.

PDF icon Keystone 65 Preferred Rx HMO Medical Grievances
Y0041_H3952_KS_13_3028 Accepted 09/12/2012

For more information on Personal Choice 65SM Medical-only PPO Medical Grievances, please reference Chapter 7, Section 9 on page 122 in your EOC or click on the link below.

PDF icon Personal Choice 65 Medical-only PPO Medical Grievances
Y0041_H3909_PC_13_2862 Accepted 09/11/2012

For more information on Personal Choice 65SM Rx PPO Medical Grievances, please reference Chapter 9, Section 10 on page 187 in your EOC or click on the link below.

PDF icon Personal Choice 65 Rx PPO Medical Grievances
Y0041_H3909_PC_13_2861 Accepted 09/12/2012

Coverage Determination for Part D Drugs

Coverage determination is the process by which the plan makes a decision about whether a Part D drug prescribed for you is covered and the amount, if any, you are required to pay. An initial coverage decision about your Part D drugs is called a ‘coverage determination.’ You, your doctor, or someone you’ve authorized may make an oral or written, standard or expedited request.

If you are a Keystone 65 Rx HMO member, you can file a coverage determination by using one of the methods below.

  • Call 1-888-678-7015.
    Calls to this number are free. 7 days a week, 8 a.m. to 8 p.m. However, please be aware that on weekends and holidays from February 15 to September 30, your call may be sent to voicemail.
  • TTY/TTD 1-888-857-4816.
  • Fax 1-888-671-5285.
  • Write FutureScripts Secure
    PO Box 37694
    Philadelphia, PA 19101-0694

If you are a Personal Choice 65SM Rx PPO member, you can file a coverage determination by using one of the methods below.

  • Call 1-888-718-3333.
    Calls to this number are free. 7 days a week, 8 a.m. to 8 p.m. However, please be aware that on weekends and holidays from February 15 to September 30, your call may be sent to voicemail.
  • TTY/TTD 1-888-857-4816.
  • Fax 1-888-671-5285.
  • Write FutureScripts Secure
    PO Box 37694
    Philadelphia, PA 19101-0694

As part of the coverage determination process, you can ask us to make an exception, including requesting coverage of drug that is not on the formulary, waiving restrictions on the plan’s coverage for a drug or asking to pay a lower-cost sharing amount. This process is called a "formulary exception." Use the Coverage Determination Form to request a formulary exception.

PDF icon Coverage Determination Form for Enrollees

PDF icon Coverage Determination Form for Providers

Coverage Determination Process

Download 2013 Coverage Determination Process

For more information on Keystone 65 Select Rx HMO’s coverage determination process, please reference Chapter 9, Section 6 on page 155 in your EOC or click on the link below.

PDF icon Keystone 65 Select Rx HMO Coverage Determination Instructions
Y0041_H3952_KS_13_3027 Accepted 09/12/2012

For more information on Keystone 65 Preferred Rx HMO’s coverage determination process, please reference Chapter 9, Section 6 on page 151 in your EOC or click on the link below.

PDF icon Keystone 65 Preferred Rx HMO Coverage Determination Instructions
Y0041_H3952_KS_13_3029 Accepted 09/12/2012

For more information on Personal Choice 65SM Rx PPO’s coverage determination process, please reference Chapter 9, Section 6 on page 156 in your EOC or click on the link below.

PDF icon Personal Choice 65 Rx PPO Coverage Determination Instructions
Y0041_H3909_PC_13_2861 Accepted 09/12/2012

Prior Authorization for Part D Drugs

For certain Part D drugs, you, your physician, or representative may need to obtain prior authorization from us before we will cover the drug. For more information on Part D Prior Authorization click here.

For Keystone 65 Select and Preferred HMO members, the plan requires prior authorization (approval in advance) of certain covered prescription drugs that have been approved by the FDA for specific medical conditions.

For more information on Keystone 65 Select Rx HMO’s prior authorization process and what services require prior authorization, please reference Chapter 4, Section 2 on page 48 in your EOC or click on the link below.

PDF icon Keystone 65 Select and Preferred Rx HMO Prior Authorization and Benefits Chart Y0041_H3952_KS_13_3027 Accepted 09/12/2012

For more information on Keystone 65 Preferred Rx HMO’s prior authorization process and what services require prior authorization, please reference Chapter 4, Section 2 on page 48 in your EOC or click on the link below.

PDF icon Keystone 65 Select and Preferred Rx HMO Prior Authorization and Benefits Chart Y0041_H3952_KS_13_3029 Accepted 09/12/2012

For Personal Choice 65SM PPO members, the plan requires prior authorization (approval in advance) of certain covered and prescription drugs that have been approved by the FDA for specific medical conditions.

For more information on Personal Choice 65SM Rx PPO’s prior authorization process and what services require prior authorization, please reference Chapter 4, Section 2 on page 47 in your EOC or click on the link below.

PDF icon Personal Choice 65 Rx PPO Prior Authorization and Benefits Chart Y0041_H3909_PC_13_2861 Accepted 09/12/2012

Part D Appeals

If you, your doctor, or your representative do not agree with the outcome of the initial coverage determination, appeal the decision by requesting a redetermination. Learn more about the appeals process by reviewing your Evidence of Coverage (EOC).

If you are a Keystone 65 HMO member, you can file a standard or expedited Part D appeal by using one of the methods below.

  • Call 1-800-645-3965.
    Calls to this number are free. 7 days a week, 8 a.m. to 8 p.m. However, please be aware that on weekends and holidays from February 15 to September 30, your call may be sent to voicemail.
  • TTY/TTD 1-888-857-4816.
  • Fax 1-888-289-3008.
  • Write Keystone 65 HMO
    Medicare Member Appeals Unit
    PO Box 13652
    Philadelphia, PA 19101-3652

If you are a Personal Choice 65SM PPO member, you can file a standard or expedited Part D appeal by using one of the methods below.

  • Call 1-800-718-3333.
    Calls to this number are free. 7 days a week, 8 a.m. to 8 p.m. However, please be aware that on weekends and holidays from February 15 to September 30, your call may be sent to voicemail.
  • TTY/TTD 1-888-857-4816.
  • Fax 1-888-289-3008.
  • Write Personal Choice 65 PPO
    Medicare Member Appeals Unit
    PO Box 13652
    Philadelphia, PA 19101-3652

Download 2013 Part D Appeals Information

For more information on Keystone 65 Select Rx HMO Part D Appeals, please reference Chapter 9, Section 6 on page 165 in your EOC or click on the link below.

PDF icon Keystone 65 Select Rx HMO Part D Appeals
Y0041_H3952_KS12_02a File & Use 09/13/2011

For more information on Keystone 65 Preferred Rx HMO Part D Appeals, please reference Chapter 9, Section 6 on page 151 in your EOC or click on the link below.

PDF icon Keystone 65 Select Rx HMO Part D Appeals
Y0041_H3952_KS12_02a File & Use 09/13/2011

For more information on Personal Choice 65SM Rx PPO Part D Appeals, please reference Chapter 9, Section 6 on page 156 in your EOC or click on the link below.

PDF icon Personal Choice 65 Rx PPO Part D Appeals
Y0041_H3909_PC_13_2861 Accepted 09/12/2012

Part D Grievances

You may file a grievance if you have a complaint other than one that involves a coverage determination (see Part D Appeals above). You would file a grievance for any type of problem you might have with us or one of our network pharmacies.

If you are a Keystone 65 HMO Member, you can file a standard or expedited Part D grievance by using one of the methods below.

  • Call 1-800-645-3965.
    Calls to this number are free. 7 days a week, 8 a.m. to 8 p.m. However, please be aware that on weekends and holidays from February 15 to September 30, your call may be sent to voicemail.
  • TTY/TTD 1-888-857-4816.
  • Fax 1-888-289-3008.
  • Write Keystone 65 HMO
    Medicare Member Appeals Unit
    PO Box 13652
    Philadelphia, PA 19101-3652

If you are a Personal Choice 65SM PPO Member, you can file a standard or expedited Part D grievance by using one of the methods below.

  • Call 1-888-718-3333.
    Calls to this number are free. 7 days a week, 8 a.m. to 8 p.m. However, please be aware that on weekends and holidays from February 15 to September 30, your call may be sent to voicemail.
  • TTY/TTD 1-888-857-4816.
  • Fax 1-888-289-3008.
  • Write Personal Choice 65 PPO
    Medicare Member Appeals Unit
    PO Box 13652
    Philadelphia, PA 19101-3652

Download 2013 Part D Grievances Information

For more information on Keystone 65 Select Rx HMO Part D Grievances, please reference Chapter 9, Section 10 on page 185 in your EOC or click on the link below.

PDF icon Keystone 65 Select Rx HMO Part D Grievances
Y0041_H3952_KS_13_3027 Accepted 09/12/2012

For more information on Keystone 65 Preferred Rx HMO Part D Grievances, please reference Chapter 9, Section 10 on page 182 in your EOC or click on the link below.

PDF icon Keystone 65 Preferred Rx HMO Part D Grievances
Y0041_H3952_KS_13_3028 Accepted 09/12/2012

For more information on Personal Choice 65SM Rx PPO Part D Grievances, please reference Chapter 9, Section 10 on page 187 in your EOC or click on the link below.

PDF icon Personal Choice 65 Rx PPO Part D Grievances
Y0041_H3909_PC_13_2861 Accepted 09/12/2012

Appointment of a Representative

If you have someone appealing our decision for you other than your physician, your appeal must include an "Appointment of Representative" form. The person taking action on your behalf is called an appointed representative. You can name a relative, friend, advocate, lawyer, or anyone else to be your appointed representative. If you want someone to act for you, then you and that person must sign and date an "Appointment of Representative" form that authorizes the person to act as your appointed representative

This statement must be sent to us at:

Medicare Appeals Unit
P.O. Box 13652
Philadelphia, PA 19101-3652

You can call Customer Service to learn how to name your appointed representative. Learn more about the appointed representative process:

PDF icon Appointment of Representative form

Evidence of Coverage

The Evidence of Coverage (EOC) is a comprehensive resource guide to your health care coverage and is considered a legal document. Use the EOC for information on the grievance, coverage determination, and appeals processes.

Contact Information

Members and providers who have questions about the exceptions and appeals processes, would like to inquire about the status of a coverage determination or appeal request, or would like aggregate statistical data on the number of grievances, appeals, and exceptions filed with the plan, please contact Customer Service.

Website last updated: 5/16/2013
Y0041_HM_13_3639d Pending

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