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 would be a letter, Remittance Advice, Coordination of Benefits documentation, etc., as applicable.
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.
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 Outdated forms will be returned to the sender for correction.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.
Provider Claim Disputes
Effective April 1, 2020, providers may submit a written post-service Provider Claim Dispute (formerly known as an appeal), for a claim payment denial or Claims Department decision, as applicable. Please note that the timely filing period for these submissions has changed from 365 calendar days to 60 calendar days, unless otherwise contracted. Additional information regarding these changes can be found on our website.
Updated Reconsideration Request Form
Neighborhood has updated its Reconsideration Request form to include another denial code for which a reconsideration may be submitted. In addition, the date of request is now required on all submissions. Please be sure to use the most current version of the request form. Effective July 1, 2020, outdated forms will be returned to the sender for correction and resubmission.
Each reconsideration request should only include the completed request form, applicable remittance advice, and medical notes. Requests submitted with claims will be returned to the sender.