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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.

Independence recently added the Member Consent for Provider to File an Appeal on my Behalf with Health Insurance Plan form to our website to streamline the process for our providers and members.

Once you have completed the form, you can send it along with your appeal to:

    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 1-800-ASK-BLUE.


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