Provider Claim Dispute & Provider-initiated Appeal Form

*Do not use this form for claim denials requiring Corrected Claims, Adjustments, or Reconsiderations*

Before completing this form for the Grievances and Appeal Unit (GAU), please consult the Claim Form Finder on NHPRI.org

If you have questions, please call Provider Services at 1-800-963-1001

Please note: All fields are required and must include attachment. One e-Form per appeal per member.

Step 1 of 3

Section 1: Member Information
Enter Member Id and Date of Birth to validate Member before proceeding with the form.
Member ID*
Member DOB*
MM slash DD slash YYYY
Start Date*
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Member Name
First Last
Member's LOB
Error Message
Do you have a Claim ID?*
Do you have a Claim ID? *
- Yes
- No
Claim ID(s)*
Click + or - at the right to add up to 10 Claim IDs. Must all be for the same member.
Section 2: Provider Information
Provider NPI*

10 Digit Number
Provider Name*
Error Message
Provider Address*
Street Address Address Line 2 City State ZIP
Contact Name*
Contact Email for e-Form Acknowledgement*
Phone Number*
Fax Number*

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