Provider Clinical Appeal Form

If you have questions, please call Provider Services at 1-800-963-1001

Please note: All fields are required and must include attachment. One e-Form per appeal per member.

Providers may use this form for reasons including, but not limited to:
  • Denial received from Neighborhood’s Utilization Management (UM) or Pharmacy Department
  • Benefit appeals on behalf of a member when the provider received a denial from Neighborhood’s UM or Pharmacy department for a non-covered service or medication
  • When a claim denies due to preauthorization previously denied by Neighborhood’s UM Department
  • Claim denied for no authorization because the provider’s office did not follow the “Post-Service (Retrospective) Authorization Requests” policy outlined in the Provider Manual
  • INTEGRITY ONLY: Denials received for prior authorization from Neighborhood’s delegated entity, Evolent, for High-End Radiology, Physical Medicine and/or Genetic Testing.