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MEDICAID MEMBERS
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- - - Neighborhood has been helping Rhode Island families stay healthy for almost 30 years by providing access to excellent health care.
COMMERCIAL MEMBERS
- - - Welcome to Neighborhood’s Commercial Member plan section. If you purchased a health plan through HealthSource RI or have a plan through your small employer, find information about your benefits here.
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- - - Welcome! We are happy to offer a health and drug plan for Rhode Islanders eligible for both Medicare and Medicaid — Neighborhood INTEGRITY (Medicare-Medicaid Plan).

Member Services Appeal Form

Member Information
Enter Member Id and Date of Birth to validate Member before proceeding with the form.
Member ID(Required)
Date of Birth(Required)
MM slash DD slash YYYY
Name(Required)
First Last
Plan Name(Required)
Member Address(Required)
Street Address Address Line 2 City State ZIP Code
Primary Telephone(Required)
Alternate telephone
Representative Information
Is this request being made by someone other than the member?(Required)
Is this request being made by someone other than the member? *
- Yes
- No
Name of the person filing the appeal(Required)
Is person Legal Representative?(Required)
Is person Legal Representative? *
- Yes
- No
Relationship to member (e.g. child, spouse)(Required)
Representative Address(Required)
Street Address Address Line 2 City State ZIP Code
Representative Primary Telephone(Required)
Representative Alternate telephone
Appeal Information
Type of Appeal(Required)
Type of Appeal *
- Standard
- Urgent
Date of appeal request(Required)
MM slash DD slash YYYY
Time of appeal request(Required)
Select Appeal Type - Standard(Required)
Select Appeal Type - Standard *
- Medical
- Pharmacy
- Claim
- Benefit Appeal
- Non-Covered DME Appeal
Select Appeal Type - Urgent(Required)
Select Appeal Type - Urgent *
- Medical
- Pharmacy
Medical appeal
Medical Authorization #(Required)
Medical Appeal - Date of Denial(Required)
MM slash DD slash YYYY
Medical Appeal - Denial Reason(Required)
Medical Appeal - Reason of Appeal(Required)
Pharmacy appeal
Name of Medication(Required)
Pharmacy appeal - Date of Denial(Required)
MM slash DD slash YYYY
Pharmacy appeal - Denial Reason(Required)
Pharmacy appeal - Reason of Appeal(Required)
Claim Appeal
Claim Number(Required)
Claim appeal - Date of Denial(Required)
MM slash DD slash YYYY
Claim appeal - Denial Reason(Required)
Claim appeal - Reason of Appeal(Required)
Benefit Appeal
Select Type of Benefit Appeal(Required)
Non Covered Service Type(Required)
Benefit Maximum Reached(Required)
Issue ID for original request(Required)
Amount(Required)
Date of Service(Required)
MM slash DD slash YYYY
Service(Required)
Provider Information(Required)
Benefit appeal - Reason of Appeal(Required)
Non Covered DME Appeal
Non Covered Service Type(Required)
Prescriber Name(Required)
Prescriber Contact Information(Required)
HCPCS Code(Required)
Diagnosis Code or Description(Required)
Vendor Name(Required)
Non Covered DME Appeal - Reason of Appeal(Required)
Member Services Representative Information
Member Services Representative Name(Required)
First Last
Member Services Representative Email(Required)
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