Keystone Direct Point-of-Service (POS)
As a Keystone Direct POS member, do I need to select a Primary Care Physician (PCP)?
Yes, Keystone Direct POS members must select a participating Keystone PCP. Your PCP will provide routine and preventive care services. In addition, your PCP will write referrals for routine X-rays, podiatry, spinal manipulation, and physical/occupational therapy services. For all other specialist services, you may seek care directly from in or out-of-network providers.
What is the difference between in-network care and out-of-network care?
In-network care references those services that are performed by providers who participate in the Keystone network. When Keystone Direct POS members seek in-network care, they receive the highest level of benefits.
Out-of-network care references those services that are performed by providers who do not participate in the Keystone network. When Keystone Direct POS members seek out-of-network care, they are subject to higher out of pocket costs, as deductible and copay apply, and they may need to submit claims to Keystone for reimbursement.
Am I responsible for the difference between the amount billed by a provider and the allowed amount when I seek care from out-of-network providers?
In addition to your deductible and coinsurance, you may be responsible for the difference between the physician's billed amount and the reasonable and customary amount when you visit a provider who does not participate in the Keystone network.
When I seek care from out-of-network providers, who is responsible to preapprove my benefits?
If you choose to utilize providers who do not participate in the Keystone network, you are responsible for contacting Care Management and Coordination by calling 1-800-227-3114 to obtain the necessary preapproval. Consult your member materials to determine what services require preapproval.