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For Members

Part C Organization Determination, Appeals, Grievances, and Out-of-Network Information

Organization Determination (Coverage Decision) for Part C

A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services or drugs. We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a service or drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal. You, your physician, or your representative may make an oral or written, standard or expedited request. When we give you our decision, we will use the standard deadlines unless we have agreed to use the expedited deadlines. A standard coverage decision means we will give you an answer within 14 days after we receive your doctor's statement. A fast coverage decision means we will answer within 72 hours after we receive your doctor's statement.

If you are a Keystone 65 HMO member, you can request an organization 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. Please note that on weekends and holidays from February 15 through September 30, your call may be sent to voicemail.
  • TTY/TTD 711.
  • Fax 1-888-289-3029.
  • Write Keystone 65 HMO
    Clinical Precertification
    1901 Market Street
    Philadelphia, PA 19103

If you are a Personal Choice 65SM PPO member, you can file an organization 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. Please note that on weekends and holidays from February 15 through September 30, your call may be sent to voicemail.
  • TTY/TTD 711.
  • Fax 1-888-289-3029.
  • Write Personal Choice 65 PPO
    Clinical Precertification
    1901 Market Street
    Philadelphia, PA 19103

If you prefer to file a grievance through CMS, please complete the Medicare Complaint Form.

2017 Organization Determination Instructions

Download 2017 Organization Determination Instructions

For more information on Keystone 65 Focus Rx HMO’s organization determination process, please reference Chapter 9, Section 5.2 on page 157 in your EOC or download below.

Keystone 65 Focus Rx HMO Organization Determination Instructions

For more information on Keystone 65 Select Medical-only HMO’s organization determination process, please reference Chapter 7, Section 5.2 on page 107 in your EOC or click on the link below.

Keystone 65 Select Medical-Only HMO Organization Determination Instructions

For more information on Keystone 65 Select Rx HMO’s organization determination process, please reference Chapter 9, Section 5.2 on page 157 in your EOC or click on the link below.

Keystone 65 Select Rx HMO Organization Determination Instructions

For more information on Keystone 65 Preferred Medical-only HMO’s organization determination process, please reference Chapter 7, Section 5.2 on page 111 in your EOC or click on the link below.

Keystone 65 Preferred HMO Medical-Only Organization Determination Instructions

For more information on Keystone 65 Preferred Rx HMO’s organization determination process, please reference Chapter 9, Section 5.2 on page 159 in your EOC or click on the link below.

Keystone 65 Preferred Rx HMO Organization Determination Instructions

For more information on Personal Choice 65SM Medical-only PPO’s organization determination process, please reference Chapter 7, Section 5.2 on page 115 in your EOC or click on the link below.

Personal Choice 65SM Medical-Only PPO Organization Determination Instructions

For more information on Personal Choice 65SM Rx PPO’s organization determination process, please reference Chapter 9, Section 5.2 on page 161 in your EOC or click on the link below.

Personal Choice 65SM Rx HMO PPO Organization Determination Instructions

Prior Authorization for Part C

For Keystone 65 Focus, 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.

2017 Prior Authorization for Part C

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 Focus Rx HMO’s prior authorization process and what services require prior authorization, please reference Chapter 4, Section 2.1 on page 51 in your EOC or click on the link below.

Keystone 65 Focus Rx HMO Prior Authorization and Benefits Chart

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 2.1 on page 43 in your EOC or click on the link below.

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 2.1 on page 43 in your EOC or click on the link below.

Keystone 65 Preferred HMO Medical-Only 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 2.1 on page 51 in your EOC or click on the link below.

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 2.1 on page 53 in your EOC or click on the link below.

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 2.1 on page 43 in your EOC or click on the link below.

Personal Choice 65SM 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 2.1 on page 49 in your EOC or click on the link below.

Personal Choice 65SM Rx HMO PPO Prior Authorization and Benefits Chart



Appeals for Part C

If you, your doctor, or your representative do not agree with the outcome of the initial organization determination, appeal the decision by requesting a reconsideration. 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. Please note that on weekends and holidays from February 15 through September 30, your call may be sent to voicemail.
  • TTY/TTD 711.
  • Fax 1-888-289-3008.
  • Write Keystone 65 HMO
    Medicare Members 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 1-888-718-3333.
    Calls to this number are free. 7 days a week, 8 a.m. to 8 p.m. Please note that on weekends and holidays from February 15 through September 30, your call may be sent to voicemail.
  • TTY/TTD 711.
  • Fax 1-888-289-3008.
  • Write Personal Choice 65 PPO
    Medicare Members Appeals Unit
    PO Box 13652
    Philadelphia, PA 19101-3652

If you prefer to file a grievance through CMS, please complete the Medicare Complaint Form.

2017 Medical Appeals Information

For more information on Keystone 65 Focus Rx HMO Medical Appeals, please reference Chapter 9, Section 4 on page 154 in your EOC or click on the link below.

Keystone 65 Focus Rx HMO Medical Appeals

For more information on Keystone 65 Select Medical-only HMO Medical Appeals, please reference Chapter 7, Section 4 on page 104 in your EOC or click on the link below.

Keystone 65 Select Medical-Only HMO Medical Appeals

For more information on Keystone 65 Select Rx HMO Medical Appeals, please reference Chapter 9, Section 4 on page 154 in your EOC or click on the link below.

Keystone 65 Select Rx HMO Medical Appeals

For more information on Keystone 65 Preferred Medical-only HMO Medical Appeals, please reference Chapter 7, Section 4 on page 108 in your EOC or click on the link below.

Keystone 65 Preferred HMO Medical-Only Medical Appeals

For more information on Keystone 65 Preferred Rx HMO Medical Appeals, please reference Chapter 9, Section 4 on page 156 in your EOC or click on the link below.

Keystone 65 Preferred Rx HMO Medical Appeals

For more information on Personal Choice 65SM Medical-only PPO Medical Appeals, please reference Chapter 7, Section 4 on page 112 in your EOC or click on the link below.

Personal Choice 65SM Medical-Only PPO Medical Appeals

For more information on Personal Choice 65SM Rx PPO Medical Appeals, please reference Chapter 9, Section 4 on page 158 in your EOC or click on the link below.

Personal Choice 65SM Rx HMO PPO Medical Appeals



Grievances for Part C

You may file a grievance if you have a complaint other than one that involves a coverage determination (see Appeals above). You would file a 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 grievance. When you file an expedited grievance, we will give you an answer to your grievance within 24 hours. You can file a standard or expedited 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. Please note that on weekends and holidays from February 15 through September 30, your call may be sent to voicemail.
  • TTY/TTD 711.
  • Fax 1-888-289-3008.
  • Write Keystone 65 HMO
    Medicare Members 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 grievance. When you file an expedited grievance, we will give you an answer to your grievance within 24 hours. You can file a standard or expedited 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. Please note that on weekends and holidays from February 15 through September 30, your call may be sent to voicemail.
  • TTY/TTD 711.
  • Fax 1-888-289-3008.
  • Write Personal Choice 65 PPO
    Medicare Members Appeals Unit
    PO Box 13652
    Philadelphia, PA 19101-3652

If you prefer to file a grievance through CMS, please complete the Medicare Complaint Form.

2017 Medical Grievances Information

For more information on Keystone 65 Focus Rx HMO grievances, please reference Chapter 9, Section 10 on page 191 in your EOC or click on the link below.

Keystone 65 Focus Rx HMO Part C Grievances

For more information on Keystone 65 Select Medical-only HMO grievances, please reference Chapter 7, Section 9 on page 130 in your EOC or click on the link below.

Keystone 65 Select Medical-Only HMO Part C Grievances

For more information on Keystone 65 Select Rx HMO grievances, please reference please reference Chapter 9, Section 10 on page 191 in your EOC or click on the link below.

Keystone 65 Select Rx HMO Part C Grievances

For more information on Keystone 65 Preferred Medical-only HMO grievances, please reference Chapter 7, Section 9 on page 134 in your EOC or click on the link below.

Keystone 65 Preferred HMO Medical-Only Part C Grievances

For more information on Keystone 65 Preferred Rx HMO grievances, please reference Chapter 9, Section 10 on page 193 in your EOC or click on the link below.

Keystone 65 Preferred Rx HMO Part C Grievances

For more information on Personal Choice 65SM Medical-only PPO grievances, please reference Chapter 7, Section 9 on page 138 in your EOC or click on the link below.

Personal Choice 65SM Medical-Only PPO Part C Grievances

For more information on Personal Choice 65SM Rx PPO grievances, please reference Chapter 9, Section 10 on page 196 in your EOC or click on the link below.

Personal Choice 65SM Rx HMO PPO Part C Grievances



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. Click here for more information.

Out-of-Network Coverage for Part C

2017 Out-of-Network Coverage for Part C

For more information on Keystone 65 Focus Rx HMO out-of-network coverage for Part C, please reference Chapter 3, Section 2.4 on page 40 or click on the link below.

Keystone 65 Focus Rx HMO Out-of-Network Coverage for Part C

For more information on Keystone 65 Select Medical-only HMO out-of-network coverage for Part C, please reference Chapter 3, Section 2.4 on page 31 or click on the link below.

Keystone 65 Select Medical-Only HMO Evidence of Coverage

For more information on Keystone 65 Select Rx HMO out-of-network coverage for Part C, please reference Chapter 3, Section 2.4 on page 39 or click on the link below.

Keystone 65 Select Rx HMO Evidence of Coverage

For more information on Keystone 65 Preferred Medical-only HMO out-of-network coverage for Part C, please reference Chapter 3, Section 2.4 on page 31 or click on the link below.

Keystone 65 Preferred HMO Medical-Only Evidence of Coverage

For more information on Keystone 65 Preferred Rx HMO out-of-network coverage for Part C, please reference Chapter 3, Section 2.4 on page 39 or click on the link below.

Keystone 65 Preferred Rx HMO Evidence of Coverage

For more information on Personal Choice 65SM Medical-only PPO Out-of-Network Coverage for Part C, please reference Chapter 3, Section 2.3 on page 31 in your EOC or click on the link below.

Personal Choice 65SM Medical-Only PPO Evidence of Coverage

For more information on Personal Choice 65SM Rx PPO Out-of-Network Coverage for Part C, please reference Chapter 3, Section 2.3 on page 37 in your EOC or click on the link below.

Personal Choice 65SM Rx HMO PPO Evidence of Coverage



For Claims and Reimbursement

Keystone 65 HMO and Personal Choice 65 PPO:
Claims Receipt Center
PO Box 211184
Eagan, MN 55121

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 please contact the Member Help Team.

To obtain an aggregate number of grievances and appeals filed with Independence Blue Cross, please mail a written request to:

Medicare Member Appeals Unit
PO Box 13652
Philadelphia, PA 19101-3652

Website last updated: 1/1/2017
Y0041_HM_17_43499f Approved 1/6/2017