Member consent form for submitting appeals for cosmetic or E/I services

October 8, 2018

As a reminder, it is necessary for a participating provider to obtain the member’s consent to appeal on his or her behalf for services that are classified as Cosmetic or Experimental/Investigational (E/I). The signed form must be included with your appeal submission.

We recently added the Member Consent for Provider to File an Appeal on my Behalf with Health Insurance Plan form to our AmeriHealth Pennsylvania website to streamline the process for our providers and members. The consent form was already available on AmeriHealth New Jersey’s website.

You can find the forms online for AmeriHealth New Jersey and AmeriHealth Pennsylvania.

Once you have completed the form, you can send it along with your appeal to the address below that corresponds with the member’s plan:

    AmeriHealth New Jersey
    Member Appeals
    259 Prospect Plains Road, Building M
    Cranbury, NJ 08512
    AmeriHealth Pennsylvania
    Member Appeals
    P.O. Box 41820
    Philadelphia, PA 19101-3652

Note: Appeals that do not include a signed member consent form cannot be processed and will be returned to the provider to take further action.

For more information, please call Customer Service at 1-888-YOUR-AH1 for AmeriHealth New Jersey or at 1-800-275-2583 for AmeriHealth Pennsylvania.