Part C coverage information
Understand how a coverage decision is handled or request a prior authorization.
Centers for Medicare and Medicaid Services (CMS) National Coverage Determinations (NCD)
The Company primarily relies on national coverage determinations (NCDs), local coverage determinations (LCDs), and other coverage guidance from the Centers for Medicare and Medicaid Services (CMS) and local Medicare contractors in the development of its Medicare Advantage medical policies. When Medicare coverage criteria are not fully established in applicable Medicare statutes, regulations, NCDs or LCDs, CMS allows Medicare Advantage plans to develop publicly accessible internal coverage criteria. The internal coverage criteria are based on current evidence in widely used treatment guidelines or clinical literature. Current, widely used treatment guidelines are those developed by organizations representing clinical medical specialties, and refers to guidelines for the treatment of specific diseases or conditions. Acceptable clinical literature includes large, randomized controlled trials or prospective cohort studies with clear results, published in a peer-reviewed journal, and specifically designed to answer the relevant clinical question, or large systematic reviews or meta-analyses summarizing the literature of the specific clinical question. For more information please see policy types and descriptions.
Visit CMS.gov for more information on the CMS NCD.
Organization determination (coverage decision) for Part C
A coverage decision is when we decide about your benefits, coverage, or the amount we will pay for your medical services or drugs.
We will use standard deadlines unless we agree to use expedited deadlines.
- Standard Coverage Decision: We will give you an answer within 7 days after we receive your doctor's statement.
- Expedited Coverage Decision: We will give you an answer within 72 hours after we receive your doctor's statement.
- Part B Drug Coverage Decision: If the decision is for a Part B drug (covered by your medical insurance, not your drug coverage), we will make a decision within 24 hours if expedited, and within 72 hours if standard.
If you are a Keystone 65 HMO/HMO-POS or Personal Choice 65SM PPO member, you can request a Part C organization determination by by calling your Member Help Team or through a written request.
Calling Member Help Team:
- Keystone 65 HMO members: Toll-free 1-800-645-3965 (TTY/TDD: 711) 8 a.m. to 8 p.m., seven days a week
- Personal Choice 65SM PPO members: Toll-free 1-888-718-3333 (TTY/TDD: 711) 8 a.m. to 8 p.m., seven days a week
Call Member Help Team
When you call, a Member Help Team representative will:
- Record your request.
- Transfer you to Health Services who can start your request and provide a pending case number.
- You’ll receive a letter with the decision once it’s made. Sometimes, we might decide that a service or drug is not covered or is no longer covered by Medicare. If you disagree with our decision, your doctor, or your representative can make a written or oral appeal request.
Written request
You need to follow specific instructions on how to submit a coverage decision request based on your health plan. For more information, please reference your plan's Evidence of Coverage (EOC) or contact the Member Help Team.
Prior authorization for Part C
Some of the services listed in the Medical Benefits Chart included in your plan's EOC are covered only if your doctor or other network provider gets approval in advance. This is called a prior authorization (also known as a “pre-approval,” or “precertification”). Your doctor or provider will request this approval for you.
- Standard Coverage Decision: We will give you an answer within 7 days after we receive your doctor's statement.
- Expedited Coverage Decision: We will give you an answer within 72 hours after we receive your doctor's statement.
- Part B Drug Coverage Decision: If the decision is for a Part B drug (covered by your medical insurance, not your drug coverage), we will make a decision within 24 hours if expedited, and within 72 hours if standard.
To know what services require prior authorization based on your health plan, please reference your plan's EOC or contact the Member Help Team.
Covered medical services and durable medical equipment (DME) that need approval in advance are marked with an asterisk (*) in the Medical Benefits Chart.
Keystone 65 HMO plans
View:
Personal Choice 65SM PPO plans
- Some in-network services need prior authorization.
- You can also get these services out-of-network, but you should request prior authorization to make sure they are covered.
View:
Covered medical services and durable medical equipment (DME) that need approval in advance are marked with an asterisk (*) in the Medical Benefits Chart.
For a list of covered medical services and durable medical equipment (DME) that need precertification/prior authorization in advance, view the documents below:
Medical specialty drugs, while administered in a hospital setting, fall under Medicare Part B. For a list of covered medical specialty drugs that need precertification/prior authorization in advance, view Specialty Drugs Requiring Precertification under Medicare Part B.
Out-of-network coverage for Part C
For more information on out-of-network coverage for Part C, please reference your plan's EOC or contact the Member Help Team.
For claims and reimbursement
Keystone 65 HMO and Personal Choice 65 PPO:
Claims Receipt Center
PO Box 211184
Eagan, MN 55121
Y0041_HM_125391_M_2026
Website last updated: 1/29/2026