Claims containing enough lines to continue onto two or more pages must only have a total charge populated on the final page. Attachments, if applicable, must be provided for each individual claim. In addition, codes and totals on the attachments must match those on the accompanying claim form. Claims not following these guidelines will be returned to the sender.
Requests for a claim adjustment must be submitted on a completed Adjustment Request Form. The original claim number must be provided on the request form, as well as in Field 64 on a UB-04 (Institutional) claim form or in Field 22 on a CMS-1500 (Professional) claim form. Requests submitted without the original claim number will be returned to the sender.
NEW – The Adjustment Request Form can now be completed online!
- Beginning September 13, 2018, adjustment requests can now be submitted electronically from our web site, rather than being mailed in. Simply complete the requested fields and add/upload attachments, as necessary. If you have any questions, please call Provider Services at 800-963-1001.
Corrected (Replacement)/Voided Claims
Requests for a claim correction must be submitted on a completed Corrected (Replacement)/Voided Claim Request Form. The original claim number must be provided on the request form, as well as in Field 64 on a UB-04 (Institutional) claim form or in Field 22 on a CMS-1500 (Professional) claim form. Requests submitted without the original claim number will be returned to the sender.
Please remember to use the most current request forms available on our website. Provider request forms are available in the Claim Forms section of the Provider Manual Forms menuon the Neighborhood website. The Corrected (Replacement)/Voided Claim, Reconsideration, Adjustment, and Appeal request forms are writeable, so they can be typed online, then printed and submitted to Neighborhood. Outdated forms will be returned to the sender for correction.
For help deciding which form to use, the Claim Form Finder, located in the Claim Formssection of the Provider Manual Forms menu on the Neighborhood website can help to determine which form must be completed and submitted to Neighborhood, along with additional information related to the submission of each form.
Paper Claim Submission Reminder
Neighborhood uses technology to scan paper forms and eliminate keystroke errors. All new and replacement/voided paper claims must therefore be submitted on original (not photocopied) print versions of the industry standard CMS-1500 and CMS-1450 (UB-04) forms, as they are printed in special optical character recognition (OCR)-scannable red ink.
Claim forms must not contain any handwritten elements, stamps, correction fluid, or staples.