Request for Reconsideration of Medicare Advantage Denial

Please submit this form to make a request for reconsideration of a Medicare Advantage denial.

Because we, Independence Blue Cross, denied your request for coverage of (or payment for) a service, you have the right to ask us for a reconsideration (appeal) of our decision. You have 60 days from the date of our Notice of Denial of Medicare Advantage Coverage to ask us for a reconsideration.

Expedited appeal requests can be made by phone at:

Keystone 65 HMO : 1-800-645-3965 (speech- and hearing-impaired 711)
Personal Choice^SM PPO: 1-888-718-3333 (speech- and hearing-impaired 711)

Member’s Information (* required fields)

* First Name:

* Last Name:

* Date of birth:

* Address:

Address 2:

* City:

* State:

* ZIP:

* Phone Number:

* Member ID (numeric portion only):

* Authorization or claim number:

Complete the following section ONLY if the person making this request is not the enrollee or prescriber:

Requestor’s Information

First name:

Last name:

Requestor’s relationship to member:

Address:

Address 2:

City:

State:

ZIP:

Phone number:

REQUEST FOR EXPEDITED REVIEW: If you or your physician believe that waiting 30 days (7 days for Part B drugs) for a standard decision could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision. If your physician indicates that waiting 30 days (7 days for Part B drugs) could seriously harm your health, we will automatically give you a decision within 72 hours. If you do not obtain your physician's support for an expedited appeal, we will decide if your case requires a fast decision. You cannot request an expedited appeal if you are asking us to pay you back for a service you already received.

I need a decision within 72 hours.

Reason for appealing

Provide any additional information you believe may help your case, such as a statement from your prescriber and relevant medical records. You may want to refer to the explanation we provided in the Notice of Denial of Medicare Advantage Coverage.

Explanation: