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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.


Please complete all information requested on this form.

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Contact information

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Patient information

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Requesting physician information

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Inpatient information (if applicable)




Please note that for Medicare Advantage members, a peer-to-peer discussion may not result in a change in the initial not certified (denial) coverage for any type of pre-service or skilled nursing facility extension determinations. The peer-to-peer discussion only affords an informal opportunity for the requesting physician to receive an explanation of the clinical basis for the adverse coverage determination. The Independence Medical Director will verbally notify the physician of first-level standard or expedited appeal rights. The provider is then directed to Member Services to begin a standard or expedited appeal as appropriate.