ࡱ> '`  bjbj$$ o FF{$6jxxx  dB000z1d2Bd~h3b94L9L9L9%;> @ } } } } } } }$h41}A;"%;AA1}L9L9~cGcGcGA8L9L9 }cGA }cGcGuD_xL93 p&0Bcv&zd4~0d~v҂Cd҂L_x҂_xHAAcGAAAAA1}1}FvAAAd~AAAABBBBBBBBB  New Jersey Department of Banking and Insurance Health Care Provider Application to Appeal a Claims Determination [Carrier Logo]Submit to: [ Carriers Name] If by mail, at: [Mailing Address for Receipt of Claims Appeals by Carrier] If by courier service, at: [Street Address for Receipt of Claims Appeals by Carrier] If electronically: [Explanation of Electronic Submission Process, if any]  You have the right to appeal Our claims determination(s) on claims you submitted to Us. You also have the right to appeal an apparent lack of activity on a claim you submitted. DO NOT submit a Health Care Provider Application to Appeal a Claims Determination IF: Our determination indicates that We concluded the health care services for which the claim was submitted were not medically necessary, were experimental or investigational, were cosmetic rather than medically necessary or dental rather than medical. INSTEAD, you may submit a request for a Stage 1 UM Appeal Review to appeal such determinations. For more information, contact: [insert contact information]. Our determination indicates that We considered the person to whom health care services for which the claim was submitted to be ineligible for coverage because the health care services are not covered under the terms of the relevant health benefits plan, or because the person is not Our member. INSTEAD, you may submit a complaint. For more information, contact: [insert contact information] We have provided you with notice that we are investigating this claim (and related ones, as appropriate) for possible fraud. You MAY submit a Health Care Provider Application to Appeal a Claims Determination IF Our determination: Resulted in the claim not being paid at all for reasons other than a UM determination or a determination of ineligibility, coordination of benefits or fraud investigation Resulted in the claim being paid at a rate you did not expect based upon the contract between you and Us, if any, or the terms of the health benefit plan. Resulted in the claim being paid at a rate you did not expect because of differences in Our treatment of the codes in the claim from what you believe is appropriate Indicated that We require additional substantiating documentation to support the claim and you believe that the required information is inconsistent with Our stated claims handling policies and procedures, or is not relevant to the claim. You also MAY submit a Health Care Provider Application to Appeal a Claims Determination IF: You believe We have failed to adjudicate the claim, or an uncontested portion of a claim, in a timely manner consistent with law, and the terms of the contract between you and Us, if any Our determination indicates We will not pay because of lack of appropriate authorization, but you believe you obtained appropriate authorization from Us or another carrier for the services You believe we have failed to appropriately pay interest on the claim You believe Our statement that We overpaid you on one or more claims is erroneous, or that the amount We have calculated as overpaid is erroneous You believe we have attempted to offset an inappropriate amount against a claim because of an effort to recoup for an overpayment on prior claims (essentially, that We have under-priced the current claim) [Carrier Logo]Submit to: [Carriers Name] If by mail, at: [ Mailing Address for Receipt of Claims Appeals by Carrier] If by courier service, at: [Street Address for Receipt of Claims Appeals by Carrier] If electronically: [Explanation of Electronic Submission Process, if any] YOU MUST COMPLETE A SEPARATE APPLICATION FOR EACH CLAIM APPEALED SIGNATURE MUST BE COMPLETE AND LEGIBLE. THIS FORM MUST BE DATED.A. Provider Information1. Provider Name:  FORMTEXT       2. TIN/NPI:  FORMTEXT      3. Provider Group (if applicable):  FORMTEXT       4. Contact Name:  FORMTEXT       5. Title:  FORMTEXT      6. Contact Address:  FORMTEXT       7. Phone:  FORMTEXT      8. Fax:  FORMTEXT      9. Email:  FORMTEXT       B. Patient Information1. Patient Name:  FORMTEXT       2. Ins. ID:  FORMTEXT      3. Did You Attach a copy of (check the appropriate response):a. The assignment of benefits?  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  NA b. The Consent to Representation in Appeals of Utilization Management Determinations and Authorization to Release of Medical Records for UM Appeal and Arbitration of Claims? (Consent form is required for review of medical records if the matter goes to arbitration.)  FORMCHECKBOX  Yes  FORMCHECKBOX  NoC. Claim Information1. Claim Number (if known):  FORMTEXT       2. Date of Service:  FORMTEXT      3. Authorization Number:  FORMTEXT      4. Claim filing method (check only one): a.  FORMCHECKBOX  electronic (submit a copy of the electronic acceptance report from Our clearinghouse or Us) b.  FORMCHECKBOX  facsimile (submit a copy of the fax transmittal) c.  FORMCHECKBOX  paper claim by mail or courier service (submit a copy of the delivery confirmation evidence)5. Check the reason(s) why you are filing this appeal (check all that apply and be specific about billing codes and reason for dispute): a.  FORMCHECKBOX  Action has not been taken on this claim b.  FORMCHECKBOX  Dispute of a denied claim ( provide date of denial:  FORMTEXT      / FORMTEXT      / FORMTEXT       c.  FORMCHECKBOX  Claim was paid but not in a timely manner (provide more information):  FORMCHECKBOX  Yes  FORMCHECKBOX  No Additional information was requested? If yes, date: FORMTEXT      / FORMTEXT      / FORMTEXT        FORMCHECKBOX  Yes  FORMCHECKBOX  No Additional information provided? If yes, date:  FORMTEXT      / FORMTEXT      / FORMTEXT        FORMCHECKBOX  Yes  FORMCHECKBOX  No Prompt Payment Interest paid correctly? d.  FORMCHECKBOX  Claim was paid, but the amount paid is in dispute e.  FORMCHECKBOX  Codes in dispute  FORMTEXT       / FORMTEXT       / FORMTEXT       / FORMTEXT       / FORMTEXT       / FORMTEXT       / FORMTEXT       / f.  FORMCHECKBOX  Dispute of an overpayment or the amount of overpayment (Attach a copy of overpayment request) g.  FORMCHECKBOX  Dispute of carriers offset amount against this claim (Attach a copy of A/R)D. 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You must be specific about billing codes and reason for dispute. The following should be submitted with your appeal (copies only): The relevant claim form The relevant Explanation(s) of Benefits or Remittance Advice A statement specifying the line items that you are appealing Copies of any overpayment requests or A/R notice Information We previously requested that you have not yet submitted, if available Itemization of the provider contract provisions you believe We are not complying with, including a copy of the pertinent section of your contract Pertinent correspondence between you and Us on this matter A description of pertinent communications between you and Us on this matter that were not in writing Relevant sections of the National Correct Coding Initiative (NCCI) or other coding support you relied upon IF the dispute concerns the disposition of billing codes Other documents you may believe support your position in this dispute (this may include medical records) Attachments:  FORMCHECKBOX  Yes  FORMCHECKBOX  No Signature: FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Date:  FORMTEXT      / FORMTEXT      / FORMTEXT       Important to Note In order to ensure your Internal Payment Appeal is eligible to meet processing requirements for the External Binding Arbitration Program The Internal Appeal Form must be sent to the address posted on Our website; The Internal Appeal Form must have a complete signature (first and last name); The Internal Appeal Form Must be Dated; There is a signed and dated Consent to Representation in Appeals of UM Determinations and Authorization for release of Medical records in UM Appeals and Independent Arbitration of Claims Form   A carriers contractors (organized delivery systems and other vendors) are subject to the same standards as the carrier when performing claim payment+,\]^¡seTCC hfh+MCJOJQJ^JaJ hfhlCJOJQJ^JaJhlCJOJQJ^JaJhCJOJQJ^JaJ hfhfCJOJQJ^JaJ hfhCJOJQJ^JaJ hfhCJOJQJ^JaJhh;)5CJaJh5CJaJ#hfh5CJOJQJ^JaJ#hfh5CJOJQJ^JaJ#hfh+M5CJOJQJ^JaJ,]A|Z\^`bdfhjlngd%t gd)} & Fgd*<~gd;)¡ˡ@ABKkʣᕇyjVj<2j*hGh)}5CJOJQJU^JaJ&jh)}5CJOJQJU^JaJh)}5CJOJQJ^JaJh)}CJOJQJ^JaJhCJOJQJ^JaJh)CJOJQJ^JaJhi JCJOJQJ^JaJ hfhCJOJQJ^JaJh=,CJOJQJ^JaJ hfh+MCJOJQJ^JaJ hfhCJOJQJ^JaJhNCJOJQJ^JaJ02NPRXZ\^lnݱsbQ=.h*<~>*CJOJQJ^JaJ&jh*<~>*CJOJQJU^JaJ hfh3,CJOJQJ^JaJ hfhCJOJQJ^JaJ hfhi6CJOJQJ^JaJhi6CJOJQJ^JaJh3,CJOJQJ^JaJ hfh)}CJOJQJ^JaJ#hf8h)}5CJOJQJ^JaJ2j+hGh)}5CJOJQJU^JaJh)}5CJOJQJ^JaJ&jh)}5CJOJQJU^JaJ¤̤Ф ҹҥ|cIc/2j,h`hj>*䴳ϴ2,`>*䴳ϴ1`>*䴳ϴԱ2+`>*䴳ϴ`>*䴳ϴ&`>*䴳ϴ1*<~>*CJOJQJU^JaJmHnHu&jh*<~>*䴳ϴ2+*<~hj>*CJOJQJU^JaJ024>BVXZdh|~ȥʥ̥éÏu[A2j8/h`hj>*CJOJQJU^JaJ2j.h`hj>*CJOJQJU^JaJ2jL.h`hj>*CJOJQJU^JaJ2j-h`hj>*CJOJQJU^JaJ2j`-h`hj>*CJOJQJU^JaJh`>*CJOJQJ^JaJ&jh`>*CJOJQJU^JaJ1jh`>*CJOJQJU^JaJmHnHu̥֥ڥ "$&024éҘvn`WC`0`W%jh3,>*CJUaJmHnHu&j$0h3,hMH>*CJUaJh3,>*CJaJjh3,>*CJUaJh3,CJaJ hfh3,CJOJQJ^JaJ hfhCJOJQJ^JaJ hfh+MCJOJQJ^JaJ2j/h`hj>*䴳ϴ`>*䴳ϴ&`>*䴳ϴ1`>*䴳ϴԱ46ݦܦ٦Ħ§򥜓oձ<#hh*<~5CJOJQJ^JaJh5CJOJQJ^JaJ#h=,h*<~5CJOJQJ^JaJ#h)}h*<~5CJ OJQJ^JaJ #h(xh=,5CJOJQJ^JaJhcG>*CJaJhf8>*CJaJhI>*CJaJ&j1h3,hMH>*CJUaJ%jh3,>*CJUaJmHnHu&j0h3,hMH>*CJUaJh3,>*CJaJjh3,>*CJUaJzħƧ/~fghnekd1$$Ifl x*x*064 lalyt(x$$If^a$gd)}$ & F$Ifa$gd)} $$Ifa$gd*<~ §ħƧ"%2;CHLMefghi̺̫̙̺̺̙̺̊{laVGhG5CJOJQJ^JaJh*<~5OJQJ^Jh)}5OJQJ^Jh5CJOJQJ^JaJh*<~5CJOJQJ^JaJhQr5CJOJQJ^JaJ#h=,hC 5CJOJQJ^JaJh 0 5CJOJQJ^JaJ#h=,h=,5CJOJQJ^JaJ#h=,h*<~5CJOJQJ^JaJ#h=,h5CJOJQJ^JaJh*<~5CJOJQJ^JaJhigd`g`gd`ggdS$a$gd*<~ij  @ƶרפ}u}d!jh}*$hn|0JCJUaJhCmCJaJhn|CJaJh}*$hn|CJaJh{rhCmjhm2Uhm2hn|hHVCJOJQJ^JaJhvfCJOJQJ^JaJU hi JhC CJOJQJ^JaJ hi Jhn|CJOJQJ^JaJ-jhi Jhn|0JCJOJQJU^JaJ" and claim processing functions (including overpayment requests)on behalf of the carrier. Use of the words We, Us or Our includes our relevant contractors.     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