How to See a Specialist

How to See a Specialist   |   Direct Access to Obstetrical/Gynecological Care   |   How to Obtain a Standing Referral
How to Have a Referred Specialist Designated as Your Primary Care Physician   |   How to Plan For Hospital Care
Continuity of Care

How to Plan For Hospital Care

If your child needs hospitalization or outpatient surgery, here are some things you should be aware of:

• Your child’s primary care physician is the one who will arrange for your child to be admitted to the hospital or to have outpatient surgery.
• Your child’s primary care physician will talk with Keystone to make sure the admission or surgery will be covered. This is called preapproval.
• If the referred specialist feels that your child needs hospitalization or outpatient surgery, the referred specialist will talk with your child’s primary care physician. If they agree, they will work together to arrange for your child’s care to be preapproved by Keystone.
• Because a hospital admission or outpatient surgery requires preapproval by Keystone, you do not need to get a referral from your physician.
• When Keystone’s patient care management department receives the information from your child’s primary care physician or referred specialist, they will evaluate the request for hospitalization or outpatient surgery based on clinical criteria guidelines. A Keystone medical director will evaluate the request. If the request is denied, you, your child’s primary care physician or referred specialist has a right to appeal this decision through the grievance process.
• While your child is in the hospital, the patient care management department will be monitoring your child’s hospital stay to assure that a plan for his or her discharge is in place. This is to make sure your child has a smooth transition from the hospital to home, or to another setting like a skilled nursing or rehabilitation facility. A Keystone case manager will work closely with your child’s primary care physician or referred specialist to help with your child’s discharge and if necessary, arrange for other medical services.
• You will receive written notification if your child’s primary care physician or referred specialist agrees with Keystone that inpatient hospitalization services are no longer required. If your child remains in the hospital after this notification, the hospital may have the right to bill you after the date of the notification. You may appeal this decision through the grievance process.