2015 Organization Determination, Appeals, and Grievances

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.

• 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 65^SM 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 2015 organization Determination Instructions

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.

Keystone 65 Basic Rx HMO Organization Determination Instructions
Y0041_H3952_KS_15_19173

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.

Keystone 65 Select Medical-only HMO Organization Determination Instructions
Y0041_H3952_KS_15_19170 accepted 09/16/2014

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.

Keystone 65 Preferred Medical-only HMO Organization Determination Instructions
Y0041_H3952_KS_15_19168 accepted 8/28/2014

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.

Keystone 65 Select Rx HMO Organization Determination Instructions
Y0041_H3952_KS_15_ 19172 accepted 08/28/2014

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.

Keystone 65 Preferred Rx HMO Organization Determination Instructions
Y0041_H3952_KS_15_19169 accepted 8/28/2014

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.

Personal Choice 65 Medical-only PPO Organization Determination Instructions
Y0041_H3909_PC_15_20189 Accepted 8/26/2014

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.

Personal Choice 65 Rx PPO Organization Determination Instructions
Y0041_H3909_PC_15_20188 accepted 8/27/2014

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.

Keystone 65 Basic Rx HMO Prior Authorization and Benefits Chart
Y0041_H3952_KS_15_19173

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.

Keystone 65 Select Medical-Only HMO Prior Authorization and Benefits Chart
Y0041_H3952_KS_15_19170 accepted 09/16/2014

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.

Keystone 65 Preferred Medical-Only HMO Prior Authorization and Benefits Chart
Y0041_H3952_KS_15_19168 accepted 8/28/2014

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.

Keystone 65 Select Rx HMO Prior Authorization and Benefits Chart
Y0041_H3952_KS_15_ 19172 accepted 08/28/2014

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.

Keystone 65 Preferred Rx HMO Prior Authorization and Benefits Chart
Y0041_H3952_KS_15_19169 accepted 8/28/2014

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.

Personal Choice 65 Medical-Only PPO Prior Authorization and Benefits Chart
Y0041_H3909_PC_15_20189 Accepted 8/26/2014

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.

Personal Choice 65 Rx PPO Prior Authorization and Benefits Chart
Y0041_H3909_PC_15_20188 accepted 8/27/2014

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.

• 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 65^SM 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 2015 Medical Appeals Information

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.

Keystone 65 Basic Rx HMO Medical Appeals
Y0041_H3952_KS_15_19173

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.

Keystone 65 Select Medical-only HMO Medical Appeals
Y0041_H3952_KS_15_19170 accepted 09/16/2014

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.

Keystone 65 Select Rx HMO Medical Appeals
Y0041_H3952_KS_15_ 19172 accepted 08/28/2014

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.

Keystone 65 Preferred Medical-only HMO Medical Appeals
Y0041_H3952_KS_15_19168 accepted 8/28/2014

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.

Keystone 65 Preferred Rx HMO Medical Appeals
Y0041_H3952_KS_15_19169 accepted 8/28/2014

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.

Personal Choice 65 Medical-only PPO Medical Appeals
Y0041_H3909_PC_15_20189 Accepted 8/26/2014

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.

Personal Choice 65 Rx PPO Medical Appeals
Y0041_H3909_PC_15_20188 accepted 8/27/2014

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.

• 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 65^SM PPO Member, 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 2015 Grievances Information

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.

Keystone 65 Basic Rx HMO Grievances
Y0041_H3952_KS_15_19173

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.

Keystone 65 Select Medical-only HMO Grievances
Y0041_H3952_KS_15_19170 accepted 09/16/2014

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.

Keystone 65 Preferred Medical-only HMO Grievances
Y0041_H3952_KS_15_19168 accepted 8/28/2014

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.

Keystone 65 Preferred Rx HMO Grievances
Y0041_H3952_KS_15_19169 accepted 8/28/2014

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.

Personal Choice 65 Medical-only PPO Grievances
Y0041_H3909_PC_15_20189 Accepted 8/26/2014

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.

Personal Choice 65 Rx PPO Grievances
Y0041_H3909_PC_15_20188 accepted 8/27/2014

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.

• Submit an online request.
• Print and mail or fax the coverage determination form. Y0041_HM_15_32556
• Call 1-888-678-7015.
  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 1-888-671-5285.
• Write FutureScripts^® Secure
  1650 Arch Street
  Suite 2600
  Philadelphia, PA 19103

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

• Submit an online request.
• Print and mail or fax the coverage determination form. Y0041_HM_15_32556
• Call 1-888-678-7015.
  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 1-888-671-5285.
• Write FutureScripts^® Secure
  1650 Arch Street
  Suite 2600
  Philadelphia, PA 19103

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.

Coverage Determination Process

Download 2015 Coverage Determination Process

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.

Keystone 65 Basic Rx HMO Coverage Determination Instructions
Y0041_H3952_KS_15_19173

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.

Keystone 65 Select Rx HMO Coverage Determination Instructions
Y0041_H3952_KS_15_ 19172 accepted 08/28/2014

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.

Keystone 65 Preferred Rx HMO Coverage Determination Instructions
Y0041_H3952_KS_15_19169 accepted 8/28/2014

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.

Personal Choice 65 Rx PPO Coverage Determination Instructions
Y0041_H3909_PC_15_20188 accepted 8/27/2014

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.

Keystone 65 Basic Rx HMO Prior Authorization and Benefits Chart
Y0041_H3952_KS_15_19173

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.

Keystone 65 Select Rx HMO Prior Authorization and Benefits Chart
Y0041_H3952_KS_15_ 19172 accepted 08/28/2014

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.

Keystone 65 Preferred Rx HMO Prior Authorization and Benefits Chart
Y0041_H3952_KS_15_19168 accepted 8/28/2014

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.

Personal Choice 65 Rx PPO Prior Authorization and Benefits Chart
Y0041_H3909_PC_15_20188 accepted 8/27/2014

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.

• Call 1-800-645-3965 (TTY/TTD 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 February 15 through September 30, your call may be sent to voicemail.
• Complete the Coverage Redetermination Request Online Submission Form
• Complete the Keystone 65 HMO Coverage Redetermination Request Form
  Y0041_HNS_14_10886 accepted 10/8/2013 and send to the plan either by fax or mail:

• Fax 1-888-289-3008.
• Mail to:
  Medicare Member Appeals Unit
  PO Box 13652
  Philadelphia, PA 19101-3652

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.

• Call 1-888-718-3333 (TTY/TTD 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 February 15 through September 30, your call may be sent to voicemail.
• Complete the Coverage Redetermination Request Online Submission Form
• Complete the Personal Choice 65^SM PPO Coverage Redetermination Request<
  Y0041_HNS_14_10886 accepted 10/8/2013 and send to the plan either by fax or mail:

• Fax 1-888-289-3008.
• Mail to:
  Medicare Member Appeals Unit
  PO Box 13652
  Philadelphia, PA 19101-3652

If our answer is yes to part or all of what you requested:

• If we approve a request for coverage, we must provide the coverage we have agreed to provide as quickly as your health requires, but no later than 7 calendar days after we receive your appeal.
• If we approve a request to pay you back for a drug you already bought, we are required to send payment to you within 30 calendar days after we receive your appeal request.

If our answer is no to part or all of what you requested:

• We will send you a written statement that explains why we said no and how to appeal our decision.

Download 2015 Part D Appeals Information

For more information on Keystone 65 Basic Rx HMO Part D Appeals, please reference Chapter 9, Section 6 on page 140 in your EOC or click on the link below.

Keystone 65 Basic Rx HMO Part D Appeals
Y0041_H3952_KS_15_19173

For more information on Keystone 65 Select Rx HMO Part D Appeals, please reference Chapter 9, Section 6 on page 139 in your EOC or click on the link below.

Keystone 65 Select Rx HMO Part D Appeals
Y0041_H3952_KS_15_ 19172 accepted 08/28/2014

For more information on Keystone 65 Preferred Rx HMO Part D Appeals, please reference Chapter 9, Section 6 on page 138 in your EOC or click on the link below.

Keystone 65 Preferred Rx HMO Part D Appeals
Y0041_H3952_KS_15_19169 accepted 8/28/2014

For more information on Personal Choice 65^SM Rx PPO Part D Appeals, please reference Chapter 9, Section 6 on page 148 in your EOC or click on the link below.

Personal Choice 65 Rx PPO Part D Appeals
Y0041_H3909_PC_15_20188 accepted 8/27/2014

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. 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 65^SM 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. 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 2015 Part D Grievances Information

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.

Keystone 65 Basic Rx HMO Part D Grievances
Y0041_H3952_KS_15_19173

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.

Keystone 65 Select Rx HMO Part D Grievances
Y0041_H3952_KS_15_ 19172 accepted 08/28/2014

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.

Keystone 65 Preferred Rx HMO Part D Grievances
Y0041_H3952_KS_15_19169 accepted 8/28/2014

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.

Personal Choice 65 Rx PPO Part D Grievances
Y0041_H3909_PC_15_20188 accepted 8/27/2014

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:

Appointment of Representative form