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Medical benefits (Part C)

Understanding your health plan is very important. Review the information below to learn about your plan's coverage and administration and make the best use of your benefits. To find out more about the benefits in your plan simply log in at ibx.com/login.

Learn more:

Centers for Medicare and Medicaid Services (CMS) National Coverage Determinations (NCD)

A National Coverage Determination (NCD) is a decision made through an evidence-based process of whether Medicare will pay for an item or service. Medicare coverage is limited to items and services that are considered "reasonable and necessary" for the diagnosis or treatment of an injury or illness (and within the scope of a Medicare benefit category).

Acupuncture for chronic low back pain

On January 21, 2020, CMS released a NCD stating that Medicare will now cover acupuncture treatment for chronic low back pain.

Coverage details

  • Up to 12 visits in a 90-day period
  • Additional eight sessions covered for patients demonstrating improvement
  • No more than 20 acupuncture treatments annually

Please see the CMS definition of chronic low back pain below:

  • Pain lasting 12 weeks or longer
  • No identifiable systemic cause (disease, infection, inflammatory, etc.)
  • Not associated with surgery
  • Not associated with pregnancy

Treatment will be discontinued after the initial 12 visits if the patient is not improving or if the patient is regressing.

All types of acupuncture, including dry needling, for any condition other than chronic low back pain are not covered by Medicare.

Physician requirements

Physicians may furnish acupuncture in accordance with applicable state requirements.

Non-physician requirements

Physician assistants, nurse practitioners/clinical nurse specialists, and auxiliary personnel must meet applicable state requirements in order to provide acupuncture treatment to Medicare beneficiaries. They must also have:

  • A masters or doctoral level degree in acupuncture or Oriental Medicine from a school accredited by the Accreditation Commission on Acupuncture and Oriental Medicine (ACAOM); and
  • Current, full, active, and unrestricted license to practice acupuncture in a state, territory, or commonwealth (i.e. Puerto Rico) of the United States, or District of Columbia.

Auxiliary personnel furnishing acupuncture must also be under the appropriate level of supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist required by CMS regulations.

Visit CMS.gov for more information on the CMS NCD.

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 14 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 14 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:

Appeals for Part C

If you, your doctor, or your representative do not agree with the outcome of the initial organization determination, you can appeal the decision by requesting a reconsideration. Learn more about the medical appeals process by reviewing your plan's EOC.

If you are a Keystone 65 HMO/HMO-POS member, you can file a standard or expedited medical appeal by using one of the methods below.

If you are a Personal Choice 65SM PPO member, you can file a standard or expedited medical appeal by using one of the methods below.

Medical appeals information

For more information on the medical appeals process, please reference your plan's EOC or contact the Member Help Team.

 

Grievances for Part C

You may file a grievance if you have a complaint other than one that involves a coverage determination (see information on appeals above). You would file a grievance for any type of problem you might have with us or one of our network providers.

If you are a Keystone 65 HMO/HMO-POS member, you can file a standard or expedited grievance. Most standard grievances are answered within 30 calendar days. When you file an expedited grievance, we will give you an answer within 24 hours. You can file a standard or expedited grievance by using one of the methods below.

  • Call 1-800-645-3965 (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.
  • Fax 1-888-289-3008.
  • Write Keystone 65 HMO
    Medicare Members Appeals Unit
    PO Box 13652
    Philadelphia, PA 19101-3652

If you are a Personal Choice 65SM PPO member, you can file a standard or expedited grievance. Most standard grievances are answered within 30 calendar days. When you file an expedited grievance, we will give you an answer within 24 hours. You can file a standard or expedited grievance by using one of the methods below.

  • Call 1-888-718-3333 (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.
  • Fax 1-888-289-3008.
  • Write Personal Choice 65 PPO
    Medicare Members Appeals Unit
    PO Box 13652
    Philadelphia, PA 19101-3652

Medical grievances information

For more information on grievances, please reference your plan's EOC or contact the Member Help Team.

If you prefer to file an appeal or grievance through CMS, please complete the Medicare Complaint Form.

To obtain an aggregate number of grievances, appeals, and exceptions filed with IBX, please contact the Member Help Team.

Appointment of a representative

If you have someone appealing our decision for you other than your physician, your appeal must include an Appointment of Representative form. View our Medicare documents page for more information.

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

Medicare Advantage medical, claims and technology policies and bulletins

Independence Blue Cross Medicare Advantage benefit programs are comprised of Medical Policy, Technology Assessments and Claims Payment policy bulletins. View our policies. By clicking this link you will be leaving the Independence Blue Cross Medicare website.

InterQual® Criteria Transparency Tool

You can access InterQual® coverage criteria through this link. This is a secure resource that helps meet regulations around transparency for care delivery. Access allows the review of InterQual criteria used to support member care decisions.

Contact information

Members and providers who have questions about the exceptions and appeals processes, would like to inquire about the status of a coverage determination or appeal request please contact the Member Help Team.

To obtain an aggregate number of grievances and appeals filed with Independence Blue Cross, please mail a written request to:

Medicare Member Appeals Unit
PO Box 13652
Philadelphia, PA 19101-3652

Evidence of coverage

Looking for additional information or details? For a complete description of benefits, visit our Medicare documents page.

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Website last updated: 12/5/2024