A Provider Claim Dispute is a post-service request for review of a denied claim typically following the adverse outcome of a Reconsideration Request, an Adjustment Request, and/or a denied or absent authorization. The majority of these reviews are administrative in nature; however, a retrospective clinical appeal review may occur for claim denials resulting from a Utilization Management Authorization Denial.
- These requests must be filed within 60 days from the Reconsideration Request and/or Adjustment Request decision date, or 60 days from the provider’s Neighborhood Remittance Advice if the Reconsideration/Adjustment request process is not applicable.
- Provider Claim Disputes are not acknowledged in writing.
- The outcome of the Provider Claim Dispute will typically be determined within sixty (60) calendar days of receipt unless additional time is needed.
- There is only one level of review for Provider Claim Disputes.
- Provider Claim Disputes are not eligible for external appeal review.
To qualify as a Provider Claim Dispute, providers must submit a Provider Claim Dispute & Provider-initiated Appeal Request Form (www.nhpri.org/providers – Provider Resources – Forms) or new Provider Claim Dispute & Provider-Initiated Appeal – eForm and include a copy of the denied claim or reference the denied claim and/or a remittance advice. Additional specific supporting documentation as to why the denial should be waived or reconsidered, is also encouraged.
All Provider Claim Disputes for retroactive authorizations must be submitted with clear rationale for why the authorization was not requested in accordance with Neighborhood preauthorization policy and a copy of the medical record in order to be processed.
Retroactive authorizations requested more than three business days after the date the service is rendered will not be considered, and claims for those services will be administratively denied for lack of authorization.
Only these circumstances will be considered as exceptions to the Provider Claim Disputes policy:
- Medicare/Medicaid retractions
- Coordination of Benefits
- Retroactive eligibility as determined by the Executive Office of Health and Human
For more information on authorizations, please consult Neighborhood’s Provider Manual.