Updated Timeframes for Claim Submission and Review Processing

January 2022

As a follow-up to the notification sent to all providers on November 1, 2021, Neighborhood Health Plan of Rhode Island (Neighborhood) wanted to remind our provider network of the changes cited below regarding claim submission timeframes and requirements.  In addition, we wanted to clarify that these changes are applicable to all providers, unless their Neighborhood contract states otherwise, as well as, clarify the date range for claim submissions.

Unless a provider’s contract with Neighborhood states otherwise, the claim submission and processing timelines detailed below will apply to all participating providers for all lines of business for:

  • Initial claims submissions for dates of service on/after January 1, 2022 and
  • Adjustments and reconsiderations for all lines of business submitted on/after January 1, 2022.

Initial Claim Submission

Neighborhood defines a complete (clean) claim as a claim or invoice for payment of healthcare services rendered. Clean claims are submitted via approved CMS claim forms or electronic formats with all required fields completed fully and accurately.

  • Clean claims must be received by Neighborhood within one hundred eighty (180) days from the date of service.
    • For date range claim submissions, (i.e., claims that require “from”/ “to” and/or “through” dates) 180 days begins at the “to”/”through” date.

Corrected Claims

Submitting a corrected claim may be necessary when the original claim was submitted with incomplete information (e.g., procedure code, date of service, diagnosis code). Providers must complete a Corrected (Replacement)/Voided Claim Request Form for accurate processing of corrected (replacement) and voided paper claims.

  • Claims must be resubmitted with all appropriate information within one hundred eighty (180) days from the date of service.
    • For date range claim submissions, (i.e., claims that require “from”/ “to” and/or “through” dates) 180 days begins at the “to”/”through” date.

Claim Adjustment

Providers may request to have an adjustment made to a previously processed claim for reasons such as, but not limited to, coordination of benefits or payment modifications.  Adjustment requests must be submitted electronically using Neighborhood’s Adjustment Request electronic form (eForm).

  • Adjustment requests of a previously adjudicated claim must be submitted within sixty (60) days from the date on the initial remittance advice (RA) statement.

Providers may also request an adjustment to a claim that has denied for timely filing if there is proof (e.g., RA,    Explanation of Benefits, or other communication confirming the claim was denied and not paid) that the provider billed another health insurer or the member within 90 days of the date of service.

  • Adjustment requests for timely filing must be submitted within sixty (60) days from the date on the RA statement of the other health insurer (or other proof).

Claim Reconsideration

A reconsideration is a review, with medical notes, of a claims payment decision.  Providers must complete a Reconsideration Request Form or the new Claim Reconsideration Request eForm and submit it with the necessary documentation.

  • Claims reconsideration requests must be submitted within sixty (60) days from the date on the initial RA or within 60 days of an adverse determination of an adjustment request.

All applicable Neighborhood documents and publications, such as the Provider Manual and website, will be updated to reflect the above changes for January 1, 2022.  This notice was also posted on the News and Updates section of the Neighborhood website.