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  • Keystone Point Of Service Out Of Network Claim Form

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88512A1b#249Info 11/30/07 9:08 AM Page 1 Keystone Point of Service REMEMBER SECTION A TYPE OR PRINT TO AVOID DELAYS, BE SURE ITEM 9, EMPLOYEES SOCIAL SECURITY # IS PROVIDED I am choosing to receive.

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Keystone First is a Medical Assistance (Medicaid) managed care health plan that was founded by the Sisters of Mercy in 1982 to help people get care, stay well, and build healthy communities.

You must file the appeal request within 60 calendar days of the date on your denial letter. You may file your request by mail, fax, or phone.

Our payer ID number is 23284.

Section 127.208 - Time for payment of medical bills (a) Payments for treatment rendered under the act shall be made within 30 days of receipt of the bill and report submitted by the provider.

Keystone First VIP Choice covers Pennsylvania residents living in Bucks, Chester, Delaware, Montgomery, and Philadelphia counties who are on both Medicaid and Medicare.

Keystone First Identification Card * The ID Card includes a three-digit alpha prefix "YXM" to the Member ID number.

Initial claims: 180 days from date of service. Resubmissions and corrections: 365 days from date of service.

Providers have 365 days from the date of service to submit claims.

Keystone Point-of-Service lets you maintain freedom of choice by allowing you to select your own doctors and hospitals. You maximize your coverage by having care provided or referred by your primary care physician (PCP).

Re-submission of previously denied claims with corrections and requests for adjustments must be submitted within 365 calendar days from the date services were rendered or compensable items were provided.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232