Keystone Mercy Health Plan

 

 

Special Notes

 

Physician Service

Referral Form Required

Case Reference

Pre-Certification

Phone Reference

 

Initiating Provider

Must Be Capitated

Primary Care

No

No

 

No Contract for this Service

Gerontology

 

 

 

Must Be Capitated

Pediatrics

No

No

 

Must Be Capitated

Care Clinic

No

No

 

 

Specialty

Care Office

Visits

 

 

Audiology

Yes

Yes

PCP

 

Cardiology

Yes

Yes

PCP

 

Dermatology

Yes

Yes

PCP

 

Ear Nose & Throat

Yes

Yes

PCP

 

GYN

No

No

 

 

Neurology

Yes

Yes

PCP

 

Nutritional Counseling

Yes

Yes

PCP

 

Oncology

Yes

Yes

PCP

 

Ophthalmology

Yes

Yes

PCP

 

Orthopedics

Yes

Yes

PCP

 

Podiatry

Yes

Yes

PCP

 

Surgery

Yes

Yes

PCP

 

Urology

Yes

Yes

PCP

 

Gilda C. Chinnici, CHAM Permission Required Riv. 2-2000

 

Specialty Care Providers can expand referrals for additional visits and/or tests for same diagnosis by calling Referral Management