The Independence Administrators prior authorization form is a one-page Provider Fax Form, available as a PDF at ibxtpa.com. You complete it with patient, provider, and service details, attach the supporting clinical records, and fax the package to 215-784-0672.1Independence Administrators. Provider Fax Form Because Independence Administrators acts as a third-party administrator for self-funded employer plans under ERISA, which services actually require precertification varies by employer group, but the form and the submission process are the same across every plan.
Where to Download the Form
The official form lives on the Independence Administrators website as a PDF titled “Provider Fax Form.”1Independence Administrators. Provider Fax Form The Philadelphia mailing address printed at the top (1900 Market Street, Suite 500) is for the company, not for submissions. Everything goes by fax.
Completing the Patient Section
Enter the patient’s full name, phone number, and date of birth exactly as they appear on the Independence Administrators member card. The form asks for a “Patient Agreement #” rather than a subscriber ID or group number. That is the plan-specific identifier printed on the member’s card. You also need to indicate whether Independence Administrators is the patient’s primary insurance, which drives coordination of benefits if another payer is involved.1Independence Administrators. Provider Fax Form
Requestor and Provider Blocks
The requestor fields capture the name, phone, and fax of the person actually submitting the form. That is usually an office coordinator or nurse rather than the physician.
Below the requestor, you fill in two separate provider blocks:
- Facility or servicing provider: name, address, and NPI of whoever will perform the service.
- Attending or ordering physician: name, address, and NPI of the physician ordering the service.
Both NPI fields are required. If the ordering physician and the servicing provider are the same person, fill both blocks in with the same information rather than leaving one blank.1Independence Administrators. Provider Fax Form
Service Details
The middle of the form describes what you are asking the plan to approve:
- Admission or service date.
- Requested number of units or days — treatment sessions, inpatient days, or units of service.
- Setting: circle inpatient, outpatient, or other. For outpatient, specify the place of service (office, hospital outpatient, free-standing clinic, or home infusion).
- Diagnosis code or codes in ICD-10.
- Procedure code or codes in CPT or HCPCS.
- Drug information, if the request involves a medication: dose, frequency, and the patient’s weight in kilograms. This matters most for infusions and injectables.
- Anticipated discharge needs for inpatient stays, such as home health or rehabilitation.
Attaching Clinical Documentation
The form states in bold that clinical information is required and must be submitted with it.1Independence Administrators. Provider Fax Form Attach office notes, lab results, imaging reports, and any documentation that shows why the requested service is medically necessary. A form faxed without clinical records behind it will not be processed as a complete request, and an incomplete submission triggers a request for additional information that restarts the review clock.
How to Submit the Completed Form
Fax the completed form and all clinical documentation to 215-784-0672.1Independence Administrators. Provider Fax Form Keep the fax confirmation page with the date and time stamped on it. That is your proof of when the review clock started.
Some practices can also submit through NaviNet, a HIPAA-compliant web portal that handles authorization transactions between providers and payers.2NantHealth. NaviNet NaviNet lets you upload clinical files digitally and track status online. Not every provider organization has NaviNet access configured for Independence Administrators, so check with your credentialing or IT staff before relying on it.
Requests That Don’t Use This Form
Two medical categories are delegated to EviCore (now part of Evernorth) rather than reviewed by Independence Administrators directly. You submit these through EviCore’s provider portal, not the fax form:3EviCore by Evernorth. Independence Administrators Provider Resources
- Genetic and genomic testing, including nucleic acid testing and certain molecular analyses. Labs are responsible for confirming a precertification is on file before running the test and must submit the request to EviCore if one is not.
- Nonemergent outpatient radiation therapy. Radiation therapy given in an inpatient hospital setting does not require separate precertification.
Pharmacy prior authorizations also follow a separate path. Prescription drug requests go to the prior authorization line at 1-888-678-7012 or by fax to 1-888-671-5285, and do not use the provider fax form.4Independence Blue Cross. Prior Authorization
For everything else, confirm whether a specific service actually needs precertification under the patient’s employer plan before you submit. Independence Administrators publishes precertification requirements on the Independence Blue Cross provider site, broken out by plan type.5Independence Blue Cross. Precertification and Cost-Share Requirements
How Long a Decision Takes
ERISA sets the outer limits. For a standard, non-urgent pre-service request, the plan has to notify you of its determination within 15 days of receiving the request. The plan can extend that window one time by another 15 days for reasons outside its control, but only if it notifies you before the initial 15 days run out and tells you what additional information it needs.6eCFR. 29 CFR 2560.503-1 – Claims Procedure
Urgent requests move much faster. When a treating physician states, orally or in writing, that applying the standard timeline could seriously jeopardize the patient’s life, health, or ability to regain normal function, the plan has 72 hours to decide.6eCFR. 29 CFR 2560.503-1 – Claims Procedure If you need an urgent review, mark it clearly on the form and have the treating physician document the clinical urgency in the attached notes.
If the Request Is Denied
A denial notice has to spell out the specific reason for the adverse determination and the clinical criteria that were applied. It also has to describe the plan’s appeal procedures and the member’s right to request relevant documents.6eCFR. 29 CFR 2560.503-1 – Claims Procedure Independence Administrators uses InterQual clinical criteria for many medical necessity reviews, so denial letters often reference specific InterQual guidelines the request did not meet.
The first step after a denial is an internal appeal. For pre-service denials where the plan offers a single level of appeal, the plan has 30 days to decide. Plans with two levels of appeal have 15 days per level.6eCFR. 29 CFR 2560.503-1 – Claims Procedure Submit any new clinical documentation, updated results, or a letter of medical necessity from the treating physician with the appeal. The appeal reviewer is often a different physician from the one who issued the initial denial, so this is the moment to put the strongest clinical case on the record.
If the internal appeal fails, the member can request an external review by an independent third party within four months of the final internal denial. Standard external reviews are decided within 45 days, and expedited reviews within 72 hours. The external reviewer’s decision binds the plan.7HealthCare.gov. External Review
What Happens If You Skip Precertification
Providing a service that required precertification without obtaining it doesn’t automatically mean the claim gets denied, but it puts payment at real risk. Independence Administrators’ policy says that failure to obtain required precertification may result in a reduction in payment or complete nonpayment to the provider for the services or drugs not precertified.5Independence Blue Cross. Precertification and Cost-Share Requirements The exact consequence depends on the employer’s plan language. Some plans impose a flat percentage reduction; others deny the claim entirely. The financial exposure usually falls on the provider rather than the member, because the provider is the party responsible for getting the authorization.
In genuine emergencies where precertification was impossible before treatment, most ERISA plans allow retrospective review within a set window after the service. Check the member’s plan documents for that filing window and submit the form with clinical records as soon as the emergency stabilizes.