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Medical Benefits (Part C)

Understanding your health plan is very important. Review the information below to learn about your plan's coverage and administration and make the best use of your benefits.  To find out more about the benefits in your plan simply log in at ibxpress.com.

New for 2019


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) (TTY/TDD: 711).
    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 April 1 through September 30, your call may be sent to voicemail.
  • 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) (TTY/TDD: 711).
    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 April 1 through September 30, your call may be sent to voicemail.
  • 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.

2019 Organization Determination Instructions

Download 2019 Organization Determination Instructions

For more information on Keystone 65 Medical-only HMO’s organization determination process, please reference Chapter 7, Section 4 on page 124 in your EOC or click on the link below.

Keystone 65 Medical-only HMO Organization Determination Instructions

For more information on Keystone 65 Rx HMO’s organization determination process, please reference Chapter 9, Section 4 on page 186 in your EOC or click on the link below.

Keystone 65 Rx HMO Organization Determination Instructions

For more information on Personal Choice 65SM Medical-only PPO’s organization determination process, please reference Chapter 7, Section 4 on page 118 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 4 on page 166 in your EOC or click on the link below.

Personal Choice 65SM Rx HMO PPO Organization Determination Instructions


2018 Organization Determination Instructions

Download 2018 Organization Determination Instructions

For more information on Keystone 65 Rx HMO’s organization determination process, please reference Chapter 9, Section 5.2 on page 179 in your EOC or click on the link below.

Keystone 65 Rx HMO Organization Determination Instructions

For more information on Keystone 65 Medical-only HMO’s organization determination process, please reference Chapter 7, Section 5.2 on page 119 in your EOC or click on the link below.

Keystone 65 Medical-Only 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 111 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 157 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 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.

2019 Prior Authorization for Part C

For Keystone 65 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 Medical-Only HMO’s prior authorization process and what services require prior authorization, please reference Chapter 4, Section 2.1 on page 45 in your EOC or click on the link below.

Keystone 65 Medical-Only HMO Prior Authorization and Benefits Chart

For more information on Keystone 65 Rx HMO’s prior authorization process and what services require prior authorization, please reference Chapter 4, Section 2.1 on page 59 in your EOC or click on the link below.

Keystone 65 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 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 2.1 on page 53 in your EOC or click on the link below.

Personal Choice 65 Rx PPO Prior Authorization and Benefits Chart


2018 Prior Authorization for Part C

For Keystone 65 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 Rx HMO's prior authorization process and what services require prior authorization, please reference Chapter 4, Section 2.1 on page 58 in your EOC or click on the link below.

Keystone 65 Rx HMO Prior Authorization and Benefits Chart

For more information on Keystone 65 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 Medical-Only 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 51 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 (TTY/TDD: 711).
    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 April 1 through September 30, your call may be sent to voicemail.
  • Fax 1-888-289-3008.
  • Write Keystone 65 HMO
    Medicare Members Appeals Unit
    PO Box 13652
    Philadelphia, PA 19101-3652
  • Complete the Request for Reconsideration of Medicare Advantage Denial Online Submission Form

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 (TTY/TDD: 711).
    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 April 1 through September 30, your call may be sent to voicemail.
  • Fax 1-888-289-3008.
  • Write Personal Choice 65 PPO
    Medicare Members Appeals Unit
    PO Box 13652
    Philadelphia, PA 19101-3652
  • Complete the Request for Reconsideration of Medicare Advantage Denial Online Submission Form

If you prefer to file an appeal through CMS, please complete the Medicare Complaint Form.

2019 Medical Appeals Information

For more information on Keystone 65 Medical-only HMO Medical Appeals, please reference Chapter 7, Section 4 on page 124 in your EOC or click on the link below.

Keystone 65 Medical-only HMO Medical Appeals

For more information on Keystone 65 Rx HMO Medical Appeals, please reference Chapter 9, Section 4 on page 186 in your EOC or click on the link below.

Keystone 65 Rx HMO Medical Appeals

For more information on Personal Choice 65SM Medical-only PPO Medical Appeals, please reference Chapter 7, Section 4 on page 118 in your EOC or click on the link below.

Personal Choice 65 Medical-only PPO Medical Appeals

For more information on Personal Choice 65SM Rx PPO Medical Appeals, please reference Chapter 9, Section 4.1 on page 166 in your EOC or click on the link below.

Personal Choice 65 Rx PPO Medical Appeals


2018 Medical Appeals Information

For more information on Keystone 65 Rx HMO's Medical Appeals, please reference Chapter 9, Section 4 on page 176 in your EOC or download below.

Keystone 65 Rx HMO Medical Appeals

For more information on Keystone 65 Medical-only HMO's Medical Appeals, please reference Chapter 7, Section 4 on page 116 in your EOC or click on the link below.

Keystone 65 Medical-Only HMO Medical Appeals

For more information on Personal Choice 65SMMedical-only PPO's Medical Appeals, please reference Chapter 7, Section 4 on page 108 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's Medical Appeals, please reference Chapter 9, Section 4 on page 154 in your EOC or click on the link below.

Personal Choice 65SM Rx 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 (TTY/TDD: 711).
    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 April 1 through September 30, your call may be sent to voicemail.
  • 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 (TTY/TDD: 711).
    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 April 1 through September 30, your call may be sent to voicemail.
  • 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.

2019 Medical Grievances Information

For more information on Keystone 65 Medical-only HMO grievances, please reference Chapter 7, Section 9.3 on page 154 in your EOC or click on the link below.

Keystone 65 Medical-only HMO Grievances

For more information on Keystone 65 Rx HMO grievances, please reference please reference Chapter 9, Section 10.3 on page 226 in your EOC or click on the link below.

Keystone 65 Rx HMO Grievances

For more information on Personal Choice 65SM Medical-only PPO grievances, please reference Chapter 7, Section 9.2 on page 146 in your EOC or click on the link below.

Personal Choice 65 Medical-only PPO Grievances

For more information on Personal Choice 65SM Rx PPO grievances, please reference Chapter 9, Section 10.3 on page 206 in your EOC or click on the link below.

Personal Choice 65 Rx PPO Grievances


2018 Medical Grievances Information

For more information on Keystone 65 Rx HMO's grievances, please reference Chapter 9, Section 10 on page 212 in your EOC or download below.

Keystone 65 Rx HMO Part C Grievances

For more information on Keystone 65 Medical-only HMO's grievances, please reference reference Chapter 7, Section 9 on page 143 in your EOC or click on the link below.

Keystone 65 Medical-Only HMO Part C Grievances

For more information on Personal Choice 65SM Medical-only PPO's grievances, please reference Chapter 7, Section 9 on page 134 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's grievances, please reference Chapter 9, Section 10 on page 192 in your EOC or click on the link below.

Personal Choice 65SM Rx 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. View our Plan Documents page for more information.


Out-of-Network Coverage for Part C

2019 Out-of-Network Coverage for Part C

For more information on Keystone 65 Medical-only HMO out of network coverage for Part C, please reference Chapter 3, Section 2.4 on page 33 or click on the link below.

Keystone 65 Medical-only HMO Out-of-Network Coverage for Part C

For more information on Keystone 65 Rx HMO out of network coverage for Part C, please reference Chapter 3, Section 2.4 on page 45 or click on the link below.

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

For more information on Personal Choice 65SM Medical-only PPO Out of Network Coverage for Part C, please reference Chapter 3, Section 2.4 on page 32 in your EOC or click on the link below.

Personal Choice 65SM Medical-Only PPO Out-of-Network Coverage for Part C

For more information on Personal Choice 65SM Rx PPO's out-of-network coverage for Part C, please reference Chapter 3, Section 2.4 on page 42 in your EOC or click on the link below.

Personal Choice 65SM Rx HMO PPO Part C Out-of-Network Coverage for Part C


2018 Out-of-Network Coverage for Part C

For more information on Keystone 65 Rx HMO's out-of-network coverage for Part C, please reference Chapter 3, Section 2.4 on page 45 in your EOC or download below.

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

For more information on Keystone 65 Medical-only HMO's out-of-network coverage for Part C, please reference Chapter 3, Section 2.4 on page 33 in your EOC or click on the link below.

Keystone 65 Medical-Only HMO Out-of-Network Coverage for Part C

For more information on Personal Choice 65SM Medical-only PPO's out-of-network coverage for Part C, please reference reference Chapter 3, Section 2.4 on page 32 on page xx in your EOC or click on the link below.

Personal Choice 65SM Medical-Only PPO Out-of-Network Coverage for Part C

For more information on Personal Choice 65SM Rx PPO's out-of-network coverage for Part C, please reference Chapter 3, Section 2.4 on page 40 in your EOC or click on the link below.

Personal Choice 65SM Rx HMO PPO Part C Out-of-Network Coverage for Part C



For Claims and Reimbursement

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


Medicare Advantage Medical, Claims and Technology Policies and Bulletins

Independence Blue Cross Medicare Advantage benefit programs are comprised of Medical Policy, Technology Assessments and Claims Payment policy bulletins. View our policies. By clicking this link you will be leaving the Independence Blue Cross Medicare website.


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

Over-the-Counter

As a member of our Medicare Advantage plans, you have a $30 quarterly allowance for over-the-counter items such as bandages, cold and allergy medicines, pain relievers, vitamins, and many more. You will receive a catalog in the mail and you can also access the catalog online at ibxmedicare.com/otc.

Telemedicine

You now have coverage — at no extra cost — for telemedicine visits for a low $5 copay. This gives you a convenient way to see a physician for non-emergency medical conditions without leaving your home. Services are available 24/7, 365 days per year. To learn more about this offered benefit, please visit ibxmedicare.com/mdlive.

Preventive Screenings

Regular checkups and screenings can help spot health conditions before they become problems. Certain preventive screenings, such as breast cancer and colorectal cancer screenings, will have a $0 copay even if they become diagnostic.

Preferred Primary Care Physician

Keystone 65 HMO plans include a Preferred PCP (primary care physician) benefit, allowing members to visit one of the hundreds of preferred doctors in our network and pay nothing out of pocket. For an up-to-date list of network providers, visit ibxmedicare.com/providerfinder.

Designated Sites

More flexibility, convenience, and choice when using physical therapy, occupational therapy, or radiology services. Your physician will tell you where to go for laboratory services. You can locate this designated site information on the front of your ID card.

Evidence of Coverage

Looking for additional information or details? For a complete description of benefits, visit our Plan Documents page.

Website last updated: 10/1/2018
Y0041_HM_19_67199 Accepted 10/1/2018

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