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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.

View IBX medical policies.

Organization determination (coverage decision) for Part C

A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services or drugs. In some cases, we might decide a service or drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal. You, your physician, or your representative may make a written standard appeal request or oral or written expedited appeal request. When we give you our decision, we will use the standard deadlines unless we have agreed to use the expedited deadlines. A standard coverage decision means we will give you an answer within 7 days after we receive your doctor's statement. An expedited coverage decision means we will answer within 72 hours after we receive your doctor's statement. If the coverage decision is for a Part B drug (covered by your medical insurance not your drug coverage) and expedited, we will make a decision within 24 hours of us receiving the request, and if standard, we will make a decision within 72 hours of us receiving the request.

If you are a Keystone 65 HMO/HMO-POS or Personal Choice 65SM PPO member, you can request a Part C organization determination by using one of the methods below.

  • Phone: Call 1-800-ASK-BLUE (1-800-275-2583) (TTY/TDD: 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 April 1 through September 30, your call may be sent to voicemail.
  • Written: You need to follow specific instructions on how to submit a coverage decision request based on your health plan in writing. For more information, please reference your plan's Evidence of Coverage (EOC) or contact the Member Help Team. Written requests can be faxed to 1-888-289-3029.

Organization determination instructions

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 (also known as “prior authorization,” “pre-approval,” or “precertification”) from us. Your doctor or other network provider can request a medical prior authorization on your behalf. A decision on a request for prior authorization for medical services can take up to 7 days, if we are waiting for information from your doctor. If the prior authorization request is for a Part B drug and expedited, we will make a decision within 24 hours of us receiving the request, and if standard, we will make a decision within 72 hours of us receiving the request.

Prior authorization for Part C

You need to follow specific instructions on prior authorization process and know what services require prior authorization request based on your health plan. For more information, 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 in the Medical Benefits Chart by an asterisk.

For Personal Choice 65SM PPO members, 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 can obtain these services out of network, and you can request prior authorization for these services to get them covered in advance.

Covered medical services and durable medical equipment (DME) that need approval in advance are marked in the Medical Benefits Chart by an asterisk.

For a list of covered medical services and durable medical equipment (DME) that need precertification/prior authorization in advance view the documents below:

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

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Website last updated: 8/15/2025