Keystone Health Plan East & Keystone 65

Special Notes	Physician Service	Encounter Form Required	Case Reference Pre-Certification Phone Reference	Initiating Provider
Must Be Capitated	Primary Care	Yes	No
Must Be Capitated	Gerontology	Yes	No
Must Be Capitated	Pediatrics	Yes	No
Must Be Capitated	Care Clinic	Yes	No
	Specialty	Care Office	Visits
	Physician Service	Referral Form Required	Case Reference Pre-Certification Phone Reference	Initiating Provider
	Audiology	Yes	Yes – for Testing	PCP
Episode of Care	Cardiology	Yes	No	PCP – each referral is good for 90 days
	Dermatology	Yes	No	PCP
	Ear Nose & Throat	Yes	No	PCP
	GYN (2 Visits)	No	No
	Neurology	Yes	No	PCP
	Nutritional Counseling	Yes	No	PCP
	Oncology	Yes	No	PCP
	Ophthalmology	Yes	No	PCP
	Orthopedics	Yes	No	PCP
Must be Capitated	Podiatry	Yes	No	PCP
	Surgery	Yes	No	PCP
	Urology	Yes	No	PCP

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