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What if I Have a Problem Getting Coverage?

If you are having a hard time getting coverage, there are steps you can take to ask for it.

Organization determinations for Medicare Part C

This is the first step to deal with requests you may have about:

  • Covering Medicare Part C medical care or service.
  • Paying for Medicare Part C medical care or service.

You, your doctor, or someone you name may ask us for an organization determination. The person you name would be your appointed representative. To learn how to do this, call Member Services at 1-800-450-1166 (TTY/TDD 711), 8 a.m. to 8 p.m., 7 days a week.

You can also fill out and mail the Appointment of Representative (AOR) Form (PDF) to:

Keystone First VIP Choice
Attn: Appeals, Grievances, and Complaints
P.O. Box 337
Essington, PA 19029

Or fax the form to: 1-855-221-0046.

We decide whether to give you, or pay for, the Medicare Part C medical care or service you are asking for. We can make a decision in 14 calendar days. We can also make a fast decision within 72 hours. A fast decision is also called an "expedited decision." If you want to find out more, see your Evidence of Coverage, Chapter 9 (PDF). You can also call Member Services for help.

Coverage determinations for Medicare Part D

This is the first step to deal with requests you may have about:

  • Covering a Medicare Part D drug you need.
  • Paying for a Medicare Part D drug you already received.

An exception is a type of coverage decision. You can ask us to make an "exception." You would do this if a drug is not covered the way you would like it to be covered.

You, your doctor, or someone you name may ask us for a coverage determination. The person you name would be your appointed representative. To learn how to name your appointed representative and get instructions, you may call Member Services. You can also fill out and return the Appointment of Representative (AOR) Form (PDF).

We make a decision to give you, or pay for, the Medicare Part D drug you are asking for. We can make a decision in 72 hours. We can also make a fast decision within 24 hours. A fast decision is also called an "expedited decision."

To learn more about a coverage determination or an exception, go to our prescription drug FAQ page.

You can also look at the Evidence of Coverage, Chapter 9 (PDF). You can also call Member Services at 1-800-450-1166 (TTY/TDD 711), 8 a.m. to 8 p.m., 7 days a week.

 

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