Commercial peer to peer (P2P) requests (excludes Medicare)

Required fields are noted with an asterisk *

Member information
*Member Id:						*Date of birth:
*Member first name:					*Member last name:				Middle initial:
Product type *Product type
Authorization information
*Current authorization number:						Current date range from:			Current date range to:
*Reason for peer to peer review:
Has it been greater than 60 days since adverse determination was made?
Has an appeal been requested?
Diagnosis code(s):						*Procedure code(s):
Notes:
Contact information
*Submitted by:						*Phone number:
*Provider contact for P2P discussion:						*Contact phone:
*Provider availability:
Additional information
Once an adverse determination is made on a Commercial product (PPO, HMO, EPO, Traditional, Indemnity), the rendering provider may contact Capital, within 15 days of original determination, to speak with the Medical Director for a P2P discussion to provide additional clinical information. Once an adverse determination is made on a Medicare or CHIP product, next step is appeal. How do I file an appeal? You may seek internal review by sending a written appeal within one hundred (180) days after receiving the Notice of Adverse Benefit Determination to: Capital Blue Cross PO Box 779518 Harrisburg, PA 17177-9518. The appeal should include the reason(s) you disagree with the Adverse Benefit Determination. To check status of appeal, contact provider services 800.471.2242.

Any questions, contact Capital Blue Cross Pre Authorization Department at 800.471.2242						UM Department Capital Blue Cross PO Box 773731 Harrisburg, PA 17177-3731
Healthcare benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company, Capital Advantage Assurance Company and Keystone Health Plan Central. Independent licensees of the Capital BlueCross BlueShield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.

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Requests are reviewed Monday through Friday, 8:00 AM through 4:30 PM.

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