Provider Administrative Appeal Form Step 1 of 3 33% Have you received an adverse determination as the result of a valid adjustment or reconsideration request?* Yes No You must submit the appropriate Adjustment or Reconsideration Request before you can submit an Administrative Appeal. Please see the form finder in the provider section of our website https://www.nhpri.org for assistance on the appropriate process. Participating Status* I am a Participating Provider I am not a Participating Provider Member InformationEnter Member ID and Date of Birth to validate Member before proceeding with the form.Member ID* Member DOB* MM slash DD slash YYYY Date of Service Start* MM slash DD slash YYYY Date of Service End* MM slash DD slash YYYY Member Name* First Last Error Message Claim number* Provider InformationGroup Billing NPI* 10 digitsHiddenProviderType Group Billing Name* Error Message Contact Name* Contact Email* Phone Number*Description*File Upload. Administrative Appeal requests with claims attached will be returned to the sender* Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 24 MB. CAPTCHA