​​New Implant Reimbursement Request Form

July 6, 2021

Independence Administrators has developed an implant reimbursement form.* Providers can fax or email this completed form to Provider Relations at:

The invoice must be attached, and the following information is required on a completed form:

  • Name of the Facility
  • Member name and ID number
  • Claim number
  • Dates of service
  • Implant type or CPT® code/Revenue code
  • Reimbursement amount

The implant reimbursement form is also available in the Claim Appeals and Reimbursements section of our website.

Learn more

If you have questions about the implant reimbursement form, please call Customer Experience at 1-844-864-4352.

*Implants are paid according to the terms of your Provider Agreement.

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