The Keystone Direct Point-of-Service (POS) benefits plan allows members to see
most providers
without a referral. Direct POS requires primary care
physician (PCP) referrals only for routine radiology, physical/ occupational
therapy, and spinal manipulations. Obtaining a referral for these services
ensures that the member receives the highest level of benefits.
For laboratory services, Direct POS members must obtain a laboratory
requisition form from their PCP or specialist. These members will be directed
to their designated (capitated) laboratory site for laboratory services. For
all other services, members may visit any Keystone Health Plan East (Keystone
HMO) network provider without a referral. Using providers in the Keystone HMO
network gives Direct POS members the highest level of benefits and the lowest
out-of-pocket costs.
Keystone?s capitation program remains in effect for Direct POS. As they would
for our Keystone HMO and POS benefits, PCPs must refer Direct POS members to
capitated providers for capitated services (i.e., radiology,
physical/occupational therapy, laboratory) for members to receive the highest
level of benefits.
Note: For podiatry services, a referral has not been required since
January 1, 2013, when the capitation program for podiatry ended.
How the plan works
Direct POS members select a participating PCP from the Keystone HMO network.
No referrals are required for Direct POS members to see participating
specialists.
Referrals are required for routine radiology, physical/occupational therapy
services, and spinal manipulation.
A requisition form is required for laboratory services.
Direct POS members are responsible for applicable cost-sharing.
Direct POS members do not need to file claim forms when services are provided
by participating specialists.
Note: For services requiring precertification through AIM Specialty
Health
®, an independent company, (CT/CT scans, MRI/MRA, nuclear
cardiology services, and PET scans), a separate PCP referral is not required.
Additionally, referrals are never required for mammography.