Provider peer-to-peer request form

If this is an urgent request, please call the Independence Blue Cross (Independence) Medical Director’s Office at 215-241-0494. For all out-of-area requests, please call 1-888-814-2244. All non-urgent calls will be returned within 24 hours.

If the member has a Medicare Product, please contact the Peer to Peer line for additional information at local 215-241-0494 or OOA 1-888-814-2244 (option 3).

If this was denied by AmeriHealth pharmacy or Optum Rx, contact Members Appeals at 1-888-671-5276, for the Peer to Peer request.

Please complete all information requested on this form.

(* required fields)

Patient information

* Patient name:

* Date of birth:

* Member ID number:

* Request/Authorization number:

* Date of admission (inpatient hosp stay):

Date of discharge (inpatient hosp stay):
Leave blank if still in facility

* Precertification services:

* Date of admission (SNF, LTAC, rehabs):

* Last Covered Day (SNF, LTAC, rehabs):

* Behavioral Health:

Inpatient
Outpatient

* Behavioral Health admission/or an Issued LCD:

Comments:

Requesting physician information

Only a NP/PA/LCSW/MD can complete a Peer to Peer with the MDR

* Provider’s name:

* NPI:

* Phone number:

Alternate phone number:

* Does the number have Voice Mail:

Yes
No

* Two days & times for call back availability:

* Email address:

To ensure your privacy, all information will be sent via a secure connection. AmeriHealth will not disclose any personal information to outside persons or entities unless we have written consent or unless authorized by law. Please see our Notice of Privacy Practices for more information.