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 IBX 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:
*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

*Requestor name:
*Requestor phone number:
*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:

You must enter a business email. We are unable to respond to your request if you submit a non-business email address (i.e., Gmail, Yahoo, etc.).