Insurance Name

 

Hospital Service

Referral Form Required

 

Pre-Certification

Phone Reference

 

Initiating Provider

 

Keystone Health Plan East

Keystone 65

Inpatient

Acute Care Elective

Non-Elective

Extended Acute

 

No

No

No

 

Yes

Yes

Yes

 

Admitting

Physician

Billing Address:

Skilled Nursing Facility

No

Yes

Admitting Physician

 

Outpatient

 

 

 

PO Box 898815

Emergency Room Visits

No

No call within 24 hours after service

 

Camp Hill, Pa. 17089

Same Day Surgery

Yes

Yes

PCP/Specialist

 

Diagnostic Radiology

Yes

No

PCP Must be Capitated

Eligibility 800-227-3116

CT Scan

Yes

No

PCP Must be Capitated

 

Stress Test

Episode

One Referral

Cardiologist

Pre-Certification 800-227-3116

Nuclear Stress Test

Of

For a 90 day

Cardiologist

 

Echo

Care

Period

Cardiologist

Provider Services 800-821-9412

Ultrasound

Yes

Yes

PCP Must be Capitated

 

Chemotherapy

Yes

Yes

PCP

 

Laboratory

 

 

 

 

Capitated with SmithKline

Yes SmithKline Form

No

 

 

STAT testing at Hospital

Yes Write stat on form

Yes

 

 

Pre-Admission Testing

Yes See note #1

 

PCP/Specialist

Referral is good for 90 days

Cardiology Department

Episode of Care

No

Cardiologist

Number of visits on referral

Physical Therapy

Yes

Yes

PCP Must be Capitated

 

Speech Therapy

Yes

Yes

PCP

Contact Person:

Occupational Therapy

Yes

Yes

PCP Must be Capitated

Patricia Wynn

Pulmonary/Respiratory

Yes

Yes

PCP/Specialist

610-225-6810

Gastroenterology

Episode of Care

No

Gastroenterologist

 

Infusion

Yes

Yes

PCP

 

Gilda C. Chinnici, CHAM Permission Required Riv. 7-99