We pay attention to your care

Keystone First’s licensed doctors and nurses monitor the services given to all members. They also make decisions about medically necessary care and services. They make these decisions using:

  • Nationally accepted clinical guidelines approved by the Department of Human Services
  • All of the medical information they are aware of
  • Your Medical Assistance benefits
  • Your personal medical needs

Keystone First does not reward health care providers for denying, limiting or delaying benefits or health care services. We also do not give incentives to our staff making decisions about medically necessary services or benefits to provide less health care coverage and services.  You may ask for a copy of the clinical guidelines used by Keystone First by calling Member Services.

Dedication to quality care

Keystone First is always looking for new ways to improve your health and to serve you better.  We look at new treatments and new technologies to see if they will be helpful to you and your family. We also send information to our providers to help them make decisions about your care.  These guidelines are taken from national and regional health care associations and task forces and medical research.

For the services they give, most PCPs get a set dollar amount each month for each member who chooses that PCP. This pays for most of the services you get from your PCP. PCPs are paid extra for some services, like shots (immunizations). When PCPs meet other quality, service and performance standards set by Keystone First, they can also get additional payments.

Keystone First also has arrangements with hospitals and doctor groups for certain kinds of services. Sometimes a global fee is paid to cover such services, whether given by the hospital, doctor group or other providers.

Providers in the Keystone First network are encouraged to give quality care to you and your family. We monitor if the health care and services are being used in the right way, and if they are appropriate and needed. We have member satisfaction surveys every year and give member education on health-related issues. If you believe you or your family got care that was not appropriate, please call Member Services. Keystone First will investigate the issue. If you would like more information about our quality improvement goals, activities or outcomes, please call Member Services.

Find out more
You can find out more about our utilization management process, please call the Keystone First utilization management department. Associate are available to answer questions Monday through Friday from 8:30 a.m. - 5:00 p.m., except when business is closed for observance of holidays, at 1-800-521-6622