Organization 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 organization determination by using one of the methods below.
If you are a Personal Choice 65 SM PPO member, you can file an organization determination by using one of the methods below.
For more information on Keystone 65 Basic Rx HMO’s organization determination process, please reference Chapter 9, Section 4 on page 129 in your EOC or download below.
For more information on Keystone 65 Select Medical-only HMO’s organization determination process, please reference Chapter 7, Section 4 on page 81 in your EOC or click on the link below.
For more information on Keystone 65 Preferred Medical-only HMO’s organization determination process, please reference Chapter 7, Section 4 on page 83 in your EOC or click on the link below.
For more information on Keystone 65 Select Rx HMO’s organization determination process, please reference Chapter 9, Section 4 on page 128 in your EOC or click on the link below.
For more information on Keystone 65 Preferred Rx HMO’s organization determination process, please reference Chapter 9, Section 4 on page 127 in your EOC or click on the link below.
For more information on Personal Choice 65 SM Medical-only PPO’s organization determination process, please reference Chapter 7, Section 4 on page 91 in your EOC or click on the link below.
For more information on Personal Choice 65 SM Rx PPO’s organization determination process, please reference Chapter 9, Section 4 on page 137 in your EOC or click on the link below.
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 Basic Rx HMO’s prior authorization process and what services require prior authorization, please reference Chapter 4, Section 2 on page 45 in your EOC or click on the link below.
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 37 in your EOC or click on the link below.
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 38 in your EOC or click on the link below.
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 45 in your EOC or click on the link below.
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 45 in your EOC or click on the link below.
For Personal Choice 65 SM 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 65 SM Medical-Only PPO’s prior authorization process and what services require prior authorization, please reference Chapter 4, Section 2 on page 35 in your EOC or click on the link below.
For more information on Personal Choice 65 SM Rx PPO’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.
Your in-network provider can request a medical prior authorization on your behalf.
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.
If you are a Personal Choice 65 SM PPO member, you can file a standard or expedited medical appeal by using one of the methods below.
For more information on Keystone 65 Basic HMO Medical Appeals, please reference Chapter 9, Section 4 on page 129 in your EOC or click on the link below.
For more information on Keystone 65 Select Medical-only HMO Medical Appeals, please reference Chapter 7, Section 4 on page 81 in your EOC or click on the link below.
For more information on Keystone 65 Select Rx HMO Medical Appeals, please reference Chapter 9, Section 4 on page 128 in your EOC or click on the link below.
For more information on Keystone 65 Preferred Medical-only HMO Medical Appeals, please reference Chapter 7, Section 4 on page 83 in your EOC or click on the link below.
For more information on Keystone 65 Preferred Rx HMO Medical Appeals, please reference Chapter 9, Section 4 on page 127 in your EOC or click on the link below.
For more information on Personal Choice 65 SM Medical-only PPO Medical Appeals, please reference Chapter 7, Section 4 on page 91 in your EOC or click on the link below.
For more information on Personal Choice 65 SM Rx PPO Medical Appeals, please reference Chapter 9, Section 4 on page 137 in your EOC or click on the link below.
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 by using one of the methods below.
If you are a Personal Choice 65 SM PPO Member, you can file a standard or expedited grievance by using one of the methods below.
For more information on Keystone 65 Basic Rx HMO grievances, please reference Chapter 9, Section 10 on page 165 in your EOC or click on the link below.
For more information on Keystone 65 Select Medical-only HMO grievances, please reference Chapter 7, Section 9 on page 109 in your EOC or click on the link below.
For more information on Keystone 65 Select Rx HMO grievances, please reference Chapter 9, Section 10 on page 167 in your EOC or click on the link below.
Keystone 65 Select Rx HMO Grievances
Y0041_H3952_KS_15_ 19172 accepted 08/28/2014
For more information on Keystone 65 Preferred Medical-only HMO grievances, please reference Chapter 7, Section 9 on page 108 in your EOC or click on the link below.
For more information on Keystone 65 Preferred Rx HMO grievances, please reference Chapter 9, Section 10 on page 164 in your EOC or click on the link below.
For more information on Personal Choice 65 SM Medical-only PPO grievances, please reference Chapter 7, Section 9 on page 116 in your EOC or click on the link below.
For more information on Personal Choice 65 SM Rx PPO grievances, please reference Chapter 9, Section 10 on page 175 in your EOC or click on the link below.
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.
If you are a Personal Choice 65 SM Rx PPO member, you can file a coverage determination by using one of the methods below.
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 or tier cost-sharing exception.” You may use the Coverage Determination Form to request an exception.
For more information on Keystone 65 Basic Rx HMO’s coverage determination process, please reference Chapter 9, Section 6 on page 140 in your EOC or click on the link below.
For more information on Keystone 65 Select Rx HMO’s coverage determination process, please reference Chapter 9, Section 6 on page 139 in your EOC or click on the link below.
For more information on Keystone 65 Preferred Rx HMO’s coverage determination process, please reference Chapter 9, Section 6 on page 138 in your EOC or click on the link below.
For more information on Personal Choice 65 SM Rx PPO’s coverage determination process, please reference Chapter 9, Section 6 on page 148 in your EOC or click on the link below.
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 Keystone 65 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 Basic Rx HMO’s prior authorization process and what services require prior authorization, please reference Chapter 5, Section 4 on page 80 in your EOC or click on the link below.
For more information on Keystone 65 Select Rx HMO’s prior authorization process and what services require prior authorization, please reference Chapter 5, Section 4 on page 79 in your EOC or click on the link below.
For more information on Keystone 65 Preferred Rx HMO’s prior authorization process and what services require prior authorization, please reference Chapter 5, Section 4 on page 78 in your EOC or click on the link below.
For Personal Choice 65 SM 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 65 SM Rx PPO’s prior authorization process and what services require prior authorization, please reference Chapter 5, Section 4 on page 88 in your EOC or click on the link below.
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.
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.
If you are a Personal Choice 65 SM PPO member, you can file a standard or expedited Part D appeal by using one of the methods below.
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.
If you are a Personal Choice 65 SM PPO Member, you can file a standard or expedited Part D grievance by using one of the methods below.
For more information on Keystone 65 Basic Rx HMO Part D Grievances, please reference Chapter 9, Section 10 on page 165 in your EOC or click on the link below.
For more information on Keystone 65 Select Rx HMO Part D Grievances, please reference Chapter 9, Section 10 on page 167 in your EOC or click on the link below.
For more information on Keystone 65 Preferred Rx HMO Part D Grievances, please reference Chapter 9, Section 10 on page 164 in your EOC or click on the link below.
For more information on Personal Choice 65 SM Rx PPO Part D Grievances, please reference Chapter 9, Section 10 on page 175 in your EOC or click on the link below.
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 the Member Help Team to learn how to name your appointed representative. Learn more about the appointed representative process:
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.
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
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 the Member Help Team.
Website last updated: 10/15/2015
Y0041_HM_16_32116b Approved 11/2/2015
*Please note that on weekends and holidays from April 1 through September 30, your call may be sent to voicemail.
To file an appeal or grievance for your medical benefit coverage or your prescription drug coverage, contact Keystone 65 Customer Service at 1-800-645-3965 or Personal Choice 65 Customer Service at 1-888-718-3333; TTY/TDD users should call 711, 7 days a week, 8 a.m. to 8 p.m.; or you can complete and submit online the Request for Medicare Prescription Drug Coverage Determination or the Request for Redetermination of Medicare Prescription Drug Denial.
For additional information from the Centers for Medicare and Medicaid Services (CMS) visit http://www.medicare.gov. If you prefer to file a grievance through CMS, please complete the Medicare Complaint Form. For additional assistance, visit The Office of the Medicare Ombudsman.
Independence Blue Cross offers Medicare Advantage plans with a Medicare contract. Enrollment in Independence Medicare Advantage plans depends on contract renewal.
Independence Blue Cross offers products through its subsidiaries Independence Hospital Indemnity Plan, Keystone Health Plan East and QCC Insurance Company — independent licensees of the Blue Cross and Blue Shield Association.
Medicare beneficiaries may also enroll in Keystone 65 HMO, Personal Choice 65 SM PPO, or Select Option ® PDP through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov.
Keystone 65 HMO and Personal Choice 65 SM PPO: For accommodation of persons with special needs at meetings call toll-free 1-877-393-6733 (711 for the speech- and hearing-impaired).
Every year, Medicare evaluates plans based on a 5-Star rating system.
MedigapFreedom: To join, you must be enrolled in Medicare Parts A and B. Plan F and Plan N are available only to applicants who enroll within six months following enrollment in Medicare Part B or who are guaranteed the right to purchase these plans under applicable federal or state laws. You must continue to pay Medicare Part A (if applicable) and Part B premiums.
COVERED PERSON means a Medicare beneficiary who is enrolled in Medicare Part A and Part B, made the appropriate payment in consideration for this Policy, and is eligible for benefits under this Policy.
Non-tobacco rates apply to applications submitted during the six-month open enrollment or in a guaranteed issue situation. Applicants NOT enrolling during the six-month open enrollment period or in a guaranteed issue situation will be evaluated for tobacco usage and charged the corresponding tobacco or non-tobacco rates. All rates are subject to change with the approval of the Pennsylvania Insurance Department. Any rate change will apply to all policies in our service area and cannot be changed or canceled because of poor health. QCC Insurance Company has the right to change premiums based on your attained age and the table of rate changes. We will give a 30-day notice of a premium change.
Benefits underwritten by QCC Insurance Company, a subsidiary of Independence Blue Cross—independent licensees of the Blue Cross and Blue Shield Association.
Not connected with or endorsed by the U.S. Government or the federal Medicare program.
The SilverSneakers ® fitness program is provided by Tivity Health, Inc., an independent company. ©2019. All rights reserved.
TruHearing ® is a registered trademark of TruHearing, Inc., an independent company.
FutureScripts ® is an independent company that provides pharmacy benefit management services.
The Independence Blue Cross OTC benefit is underwritten by Keystone Health Plan East/QCC and is administered by Convey Health Solutions, Inc., an independent company.
Telemedicine is provided by MDLIVE, an independent company. MDLIVE may not be available in certain states and is subject to state regulations. MDLIVE does not replace the primary care physician, is not an insurance product and may not be able to substitute for traditional in-person care in every case or for every condition. MDLIVE does not prescribe DEA-controlled substances and may not prescribe non-therapeutic drugs and certain other drugs, which may be harmful because of their potential for abuse. MDLIVE does not guarantee patients will receive a prescription. Health care professionals using the platform have the right to deny care if based on professional judgment a case is inappropriate for telehealth or for misuse of services. MDLIVE and the MDLIVE logo are registered trademarks of MDLIVE, Inc. and may not be used without written permission. For complete terms of use visit https://www.mdlive.com/terms-of-use/.
Out-of-network/non-contracted providers are under no obligation to treat Independence Blue Cross Medicare members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.
The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.
Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2020, and from time to time during the year.
© Independence Blue Cross
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.
