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Neighborhood Provider Claims - Frequently Asked Questions [ Click Here to Learn How to Submit Claims Electronically to Neighborhood ] The Claims Department staff is available Monday through Friday from 10:00 am to 3:00 pm. Please call 401-459-6080 or 1-800 963-1001.
How should I (provider) bill for immunization services?
How do I coordinate DME services?
How do I coordinate behavioral health services?
I saw a patient that was not assigned to me, what should I do?
If I have a question regarding a denial of a claim, whom should I call?
If I need assistance regarding outstanding claims, whom should I contact?
Where do I submit behavioral health service claims?
What is a Complete Claim?
Where do I put the provider number and vendor number when I’m completing a claim?
Why was my claim denied?
How do I know which code to use for a particular procedure?
What is the process for an Auto Audit Reconsideration?
How should I (provider) bill for immunization services?
When submitting claims for an immunization it is necessary to submit a claim reflecting both the immunization itself, and the administration of the vaccine. If vaccine is state supplied the billed amount for the vaccine should reflect $0.00. In order to receive payment it is necessary to bill for both the vaccine, and the administration of it. If vaccine is State supplied no reimbursement will be made for the vaccine.
Use the following codes for the administration of vaccines:
90471 for the first vaccine
90472 for any additional vaccines
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How do I coordinate DME services?
In order for Neighborhood to cover DME services they must be authorized. You should contact the Care Management Department at Neighborhood prior to ordering DME.
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How do I coordinate behavioral health services?
Beacon Health Strategies is responsible for coordinating and managing Neighborhood members' behavioral health care services. Neighborhood providers and/or members may directly refer their patients to a Beacon behavioral health provider. You do not need to contact Beacon. However, if you need assistance identifying a behavioral health provider or coordinating care rather than facilitating a direct referral, you should contact Beacon at 1-800-414-2820.
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I saw a patient that was not assigned to me, what should I do?
If upon verifying eligibility and site assignment, your office learns that an eligible member is assigned to another primary care site, please complete a Member Site Change Request Form and have the member (or member's parent/head of household) sign the completed form. A copy of the Member Site Change Request Form is located in Section 12, Provider Forms, of the Provider Manual, and located on the website at Provider Forms. The completed and signed form should be faxed to Neighborhood Health Plan of Rhode Island (Neighborhood) at 401 459-6021. Or you may have the member (or member's parent/head of household) contact the Member Services Department at 1-800-459-6019. Providers have five (5) business days from the date of service to fax the Member Site Change Request Form to Neighborhood.
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If I have a question regarding a denial of a claim should I call?
You should contact the Claims Department directly regarding any questions that you have regarding the denial of your claims.
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If I need assistance regarding outstanding claims whom should I contact?
You should contact the Claims Department directly if you are checking on a few claims. If you have multiple claims (over 10) we would ask that you contact your Provider Relations Representative directly. Your Provider Relations Representative will work in conjunction with claims staff to resolve your questions and concerns.
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Where do I submit behavioral health service claims?
We have contracted with Beacon Health Strategies to manage our behavioral health services, process and pay claims. Claims should be submitted directly to: Beacon Health Strategies
500 Unicorn Park Drive
Woburn, MA 01801 If you have any claims questions related to behavioral health, contact Beacon's Call Center at 800-414-2820.
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What is a Complete Claim?
A Complete Claim is an invoice received from a health care provider in a timely manner, usually within 90 days from the date of service. It contains accurate information in Neighborhood-required format that does not require Neighborhood to further investigate or acquire additional information from the provider or other sources, either internal or external. Complete claims have no defect or impropriety (including any lack of required substantiating documentation) or particular circumstances requiring special treatment that would delay payment from being made promptly.
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Where do I put the provider number and vendor number when I’m completing a claim?
Participating providers should record their provider number and vendor number in Field (Box) 33, on the CMS 1500 claim form. Nonparticipating providers should record their Provider Identification Number (PIN #) in this field. This is a required field. For more information regarding completing the CMS 1500 claims form, please refer to the Provider Manual, Section 3, Billing and Reimbursement, pages 24-25, or contact the Claims Department.
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Why was my claim denied?
The Neighborhood Remittance Advise (RA) form will provide you with information regarding a denied claim. For further assistance regarding a claim that was denied, or other billing issue, please contact the Claims Department.
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How do I know which code to use for a particular procedure?
As you submit your claims to Neighborhood for review and potential reimbursement, please follow the Physicians Current Procedural Terminology (CPT) and ICD – 9 guidelines.
^ back to top What is the process for an Auto Audit Reconsideration?
Auto Audit edits which require submission of medical documentation for reconsideration should be faxed to the Claims Quality Department at 401- 459-6146. A cover sheet, the claim, Remittance Advice form along with supporting documents is needed for reconsideration.
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