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2016 Organization Determination, Appeals, and Grievances

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 72 hours after we receive your doctor's statement. An fast coverage decision means we will answer within 24 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 1-888-289-3008.
  • 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 1-888-289-3008.
  • Write Personal Choice 65 PPO
    Clinical Precertification
    1901 Market Street
    Philadelphia, PA 19103

Organization Determination Instructions

Download 2016 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 145 in your EOC or download below.

PDF icon Keystone 65 Focus Rx HMO Organization Determination Instructions
Y0041_H3952_KS_16_31546 accepted 08/28/2015

For more information on Keystone 65 Select Medical-only HMO’s organization determination process, please reference Chapter 7, Section 5.2 on page 103 in your EOC or click on the link below.

PDF icon Keystone 65 Select Medical-only HMO Organization Determination Instructions
Y0041_H3952_KS_16_31545 accepted 08/28/2015

For more information on Keystone 65 Preferred Medical-only HMO’s organization determination process, please reference Chapter 7, Section 5.2 on page 97 in your EOC or click on the link below.

PDF icon Keystone 65 Preferred Medical-only HMO Organization Determination Instructions
Y0041_H3952_KS_16_31544 accepted 08/28/2015

For more information on Keystone 65 Select Rx HMO’s organization determination process, please reference Chapter 9, Section 5.2 on page 149 in your EOC or click on the link below.

PDF icon Keystone 65 Select Rx HMO Organization Determination Instructions
Y0041_H3952_KS_16_31546 accepted 08/28/2015

For more information on Keystone 65 Preferred Rx HMO’s organization determination process, please reference Chapter 9, Section 5.2 on page 145 in your EOC or click on the link below.

PDF icon Keystone 65 Preferred Rx HMO Organization Determination Instructions
0041_H3952_KS_16_31491 accepted 08/28/2015

For more information on Personal Choice 65SM Medical-only PPO’s organization determination process, please reference Chapter 7, Section 5.2 on page 109 in your EOC or click on the link below.

PDF icon Personal Choice 65 Medical-only PPO Organization Determination Instructions
Y0041_H3909_PC_16_32918 accepted 08/28/2015

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.

PDF icon Personal Choice 65 Rx PPO Organization Determination Instructions
Y0041_H3909_PC_16_32919 accepted 08/28/2015


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.

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 on page 51 in your EOC or click on the link below.

PDF icon Keystone 65 Focus Rx HMO Prior Authorization and Benefits Chart
Y0041_H3952_KS_16_31546 accepted 08/28/2015

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 43 in your EOC or click on the link below.

PDF icon Keystone 65 Select Medical-Only HMO Prior Authorization and Benefits Chart
Y0041_H3952_KS_16_31545 accepted 08/28/2015

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 43 in your EOC or click on the link below.

PDF icon Keystone 65 Preferred Medical-Only HMO Prior Authorization and Benefits Chart
Y0041_H3952_KS_16_31544 accepted 08/28/2015

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 51 in your EOC or click on the link below.

PDF icon Keystone 65 Select Rx HMO Prior Authorization and Benefits Chart
Y0041_H3952_KS_16_31546 accepted 08/28/2015

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 51 in your EOC or click on the link below.

PDF icon Keystone 65 Preferred Rx HMO Prior Authorization and Benefits Chart
Y0041_H3952_KS_16_31491 accepted 08/28/2015

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 41 in your EOC or click on the link below.

PDF icon Personal Choice 65 Medical-Only PPO Prior Authorization and Benefits Chart
Y0041_H3909_PC_16_32918 accepted 08/28/2015

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 49 in your EOC or click on the link below.

PDF icon Personal Choice 65 Rx PPO Prior Authorization and Benefits Chart
Y0041_H3909_PC_16_32919 accepted 08/28/2015

Your in-network provider can request a medical prior authorization on your behalf.


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 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 1-888-718-3333.
    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 Member Appeals Unit
    PO Box 13652
    Philadelphia, PA 19101-3652

Download 2016 Medical Appeals Information

For more information on Keystone 65 Focus HMO Medical Appeals, please reference Chapter 9, Section 4 on page 142 in your EOC or click on the link below.

PDF icon Keystone 65 Focus Rx HMO Medical Appeals
Y0041_H3952_KS_16_31546 accepted 08/28/2015

For more information on Keystone 65 Select Medical-only HMO Medical Appeals, please reference Chapter 7, Section 4 on page 100 in your EOC or click on the link below.

PDF icon Keystone 65 Select Medical-only HMO Medical Appeals
Y0041_H3952_KS_16_31545 accepted 08/28/2015

For more information on Keystone 65 Select Rx HMO Medical Appeals, please reference Chapter 9, Section 4 on page 146 in your EOC or click on the link below.

PDF icon Keystone 65 Select Rx HMO Medical Appeals
Y0041_H3952_KS_16_31546 accepted 08/28/2015

For more information on Keystone 65 Preferred Medical-only HMO Medical Appeals, please reference Chapter 7, Section 4 on page 94 in your EOC or click on the link below.

PDF icon Keystone 65 Preferred Medical-only HMO Medical Appeals
Y0041_H3952_KS_16_31544 accepted 08/28/2015

For more information on Keystone 65 Preferred Rx HMO Medical Appeals, please reference Chapter 9, Section 4 on page 142 in your EOC or click on the link below.

PDF icon Keystone 65 Preferred Rx HMO Medical Appeals
Y0041_H3952_KS_16_31491 accepted 08/28/2015

For more information on Personal Choice 65SM Medical-only PPO Medical Appeals, please reference Chapter 7, Section 4 on page 106 in your EOC or click on the link below.

PDF icon Personal Choice 65 Medical-only PPO Medical Appeals
Y0041_H3909_PC_16_32918 accepted 08/28/2015

For more information on Personal Choice 65SM Rx PPO Medical Appeals, please reference Chapter 9, Section 4 on page 154 in your EOC or click on the link below.

PDF icon Personal Choice 65 Rx PPO Medical Appeals
Y0041_H3909_PC_16_32919 accepted 08/28/2015


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

Download 2016 Grievances Information

For more information on Keystone 65 Focus Rx HMO grievances, please reference Chapter 9, Section 10 on page 179 in your EOC or click on the link below.

PDF icon Keystone 65 Focus Rx HMO Grievances
Y0041_H3952_KS_16_31546 accepted 08/28/2015

For more information on Keystone 65 Select Medical-only HMO grievances, please reference Chapter 7, Section 9 on page 126 in your EOC or click on the link below.

PDF icon Keystone 65 Select Medical-only HMO Grievances
Y0041_H3952_KS_16_31545 accepted 08/28/2015

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

PDF icon Keystone 65 Select Rx HMO Grievances
Y0041_H3952_KS_16_31546 accepted 08/28/2015

For more information on Keystone 65 Preferred Medical-only HMO grievances, please reference Chapter 7, Section 9 on page 120 in your EOC or click on the link below.

PDF icon Keystone 65 Preferred Medical-only HMO Grievances
Y0041_H3952_KS_16_31544 accepted 08/28/2015

For more information on Keystone 65 Preferred Rx HMO grievances, please reference Chapter 9, Section 10 on page 180 in your EOC or click on the link below.

PDF icon Keystone 65 Preferred Rx HMO Grievances
Y0041_H3952_KS_16_31491 accepted 08/28/2015

For more information on Personal Choice 65SM Medical-only PPO grievances, please reference Chapter 7, Section 9 on page 132 in your EOC or click on the link below.

PDF icon Personal Choice 65 Medical-only PPO Grievances
Y0041_H3909_PC_16_32918 accepted 08/28/2015

For more information on Personal Choice 65SM Rx PPO grievances, please reference Chapter 9, Section 10 on page 190 in your EOC or click on the link below.

PDF icon Personal Choice 65 Rx PPO Grievances
Y0041_H3909_PC_16_32919 accepted 08/28/2015


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

Keystone 65 HMO

Keystone 65 HMO members must receive = care from a network provider. In most cases, care received from an out-of-network provider (a provider who is not part of our plan) will not be covered

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 39 or click on the link below.

PDF icon Keystone 65 Focus Rx HMO Out of Network Coverage for Part C
Y0041_H3952_KS_16_31546 accepted 08/28/2015

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.

PDF icon Keystone 65 Select Medical-only HMO Out of Network Coverage for Part C
Y0041_H3952_KS_16_31545 accepted 08/28/2015

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.

PDF icon Keystone 65 Select Rx HMO Out of Network Coverage for Part C
Y0041_H3952_KS_16_31546 accepted 08/28/2015

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.

PDF icon Keystone 65 Preferred Medical-only HMO Out of Network Coverage for Part C
Y0041_H3952_KS_16_31544 accepted 08/28/2015

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.

PDF icon Keystone 65 Preferred Rx HMO Out of Network Coverage for Part C
Y0041_H3952_KS_16_31491 accepted 08/28/2015

Personal Choice 65 PPO

Personal Choice 65SM PPO members can choose to receive care from out-of-network providers. Personal Choice 65SM PPO will cover services from either network or out-of-network providers, as long as the services are covered benefits and are medically necessary. However, if you use an out-of-network provider, your share of the costs for your covered services may be higher.

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 29 in your EOC or click on the link below.

PDF icon Personal Choice 65 Medical-only PPO Out of Network Coverage for Part C
Y0041_H3909_PC_16_32918 accepted 08/28/2015

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.

PDF icon Personal Choice 65 Rx PPO Out of Network Coverage for Part C
Y0041_H3909_PC_16_32919 accepted 08/28/2015

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.

For Claims and Reimbursement

Keystone 65 HMO:
c/o Service Center
PO Box 69353
Harrisburg, PA 17106-9353

Personal Choice 65 PPO:
c/o Service Center
PO Box 69352
Harrisburg, PA 17106-9352

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: 6/23/2016
Y0041_HM_16_32116k Pending

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