Adjustment Request Form
Neighborhood’s Adjustment Request form is now available online in a secure electronic format, which will save time and postage! The online form is the only Adjustment Request form that is needed; expected attachments, if applicable, would be a letter, Remittance Advice, Coordination of Benefits documentation, etc.
Electronic Reconsideration Correspondence
Neighborhood has incorporated a new process for handling reconsideration requests. Now, when a reconsideration request is submitted on paper or electronically, correspondence letters will be sent back to the provider via a “Do Not Reply” email in the event that the adjustment cannot be made. This email correspondence will include the information previously provided by the paper letter. Providers are encouraged to submit a current/valid e-mail address to ensure a faster turnaround time on their requests.
When calling to obtain the status of documents sent to Neighborhood via certified mail, submitters must provide the mail tracking number from the bar code on the package. Use of this number makes it faster and easier to track Neighborhood deliveries.
Please remember to use the most current request forms available on our website. Provider request forms are available in the Forms section of the Provider Resources menu on the Neighborhood website. The Corrected Claim, Reconsideration, 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 Outdated forms will be returned to the sender for correction.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 Forms section of the Provider Resources 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.
Claim Submission Reminders for Providers and Billers
- Neighborhood uses technology to scan paper forms and eliminate keystroke errors. All new and corrected claims must 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.
- Data entered on the claim form must be properly aligned and fall completely within the applicable text fields. Data that is misaligned or ghosted elsewhere on the form is systematically recognized as an error and will result in the claim being returned to the sender for correction.
- It is not necessary to provide a W-9 form with a claim unless it is the first time a claim is submitted to Neighborhood on a provider’s behalf.