Provider Appeal Process
If you received a remittance advice from Network Health that shows a denied claim, the first step is to determine the reason the claim was not processed as you expected. This can be accomplished by:
- Reviewing the denial message printed on your remittance advice document, and/or
- Contacting the Customer Service department for clarification.
After completing the above steps, if there are still concerns about the claim and there are extenuating circumstances, you may file a provider appeal or a claim action request. Please see the helpful hints to the left to assist in determining the type of action to consider.
Provider Appeals
You may file an appeal by submitting a Provider Appeal form to our Network Development department. You have 15 months from the date of the claim remittance advice to submit an appeal. All applicable fields of the Provider Appeal form need to be completed in full in order to be processed. If information is missing, the request cannot be reviewed.
Provider appeals will be reviewed within 45 business days from the date we receive the request. All decisions are final. You will be notified in writing within 5 business days of the decision.
Claims Action Requests
If the claim denial is related to bundling, modifiers, global days, or incorrect payment, (see terms at left), please submit a Claims Action form within 15 months from the date of the claim remittance advice. All applicable fields of the Claims Action Form need to be completed in full in order to process the request. After the request is received and reviewed, a claims action determination form will be faxed to you within 45 business days.
Please Note: If your claims question is not related to an issue that is covered by either the Provider Appeal or Claims Action terms, please contact the Customer Service department.
Helpful Terms:
Provider Appeal Form:
Used for claims denied for provider financial responsibility when the authorization process was not followed due to an unusual circumstance.
Claims Action Form:
Used for claims denied for provider financial responsibility due to bundling, modifier, or incorrect payment.
Global Days:
Service was billed within the global period.
Bundling:
Services billed were bundled into a package and should not be billed separately.
Modifier:
Modifier is required for payment or modifier reduced payment.
Incorrect Payment:
Provider is requesting review of payment for issues such as endoscopic rules, modifier, bundling, global days, etc.