Claim Submission Requirements – Effective August 1, 2023, Neighborhood has transitioned to electronic claim submissions for all lines of business, except those requiring attachments. Click here for the full notification.
Eligibility Information
Neighborhood is contracted with NaviNet to provide online member benefit, eligibility, and claims status lookup. Both contracted and non-contracted (out-of-network) providers can use NaviNet. Neighborhood created a Cross-Reference Guide that identifies the equivalent Plan ID for the Group Number displayed in NaviNet to assist users. For additional help or information, contact Neighborhood Provider Services at 1-800-963-1001.
Claims Submission Information
Claims that do not require an attachment must be filed electronically. All Commercial and Medicaid
coordination of benefit (COB) claims, also known as secondary claims, must also be submitted
electronically.
For electronic submissions, use the proper payer ID for the applicable line of business:
- Medicaid/Commercial Claims Payer ID 05047
- INTEGRITY (Medicare-Medicaid Plan) Claims Payer ID 96240
Neighborhood has partnered with claims clearinghouses Change Healthcare, Inovalon (formerly known as ABILITY), Waystar, and Healthcare Revenue Cycle Solutions (SSI) to offer providers a way to submit all Neighborhood claims electronically.
For information and guidance on requesting an adjustment to a previously processed claim(s), please click here.
Each Neighborhood line of business has certain levels of appeal and submission timeframes, outlined in the Provider Appeal Process and Timelines reference table.
Claims with any type of attachment, including, but not limited to the following, must be submitted in paper
form:
• Explanation of Benefits (EOB)
• Medical records
• Invoices
• Single case agreements
Paper claims can be mailed to the following address:
Neighborhood Health Plan of Rhode Island
Attention: Claims Department
P.O. Box 28259
Providence, RI 02908-3700
When filing on paper, submissions must be on original red forms. Claim submissions that are carbon copies, photocopies, difficult to interpret, faint in image, misaligned, or missing information, will be returned for resubmission.
INTEGRITY Provider Appeal Rights
Participating Providers: Please consult Neighborhood’s Provider Manual for appeal rights.
Non-participating Providers: If you disagree with the amount of the payment or denial for the service(s) rendered, you have the right to request a reconsideration or appeal. You must file your appeal within 60 days of the date on the remittance notification. To file an appeal, send a written appeal to Neighborhood Health Plan of Rhode Island Attn: Grievance and Appeals Coordinator 910 Douglas Pike Smithfield, RI 02917. Please supply additional written documentation with your appeal to include comments, clinical records, or other documentation that supports your appeal. We will review our initial decision and notify you in writing of the outcome of your appeal. We will respond to administrative appeals within 60 calendar days and medical necessity appeals within 30 calendar days of receipt. Please note if you choose to appeal, you must also submit a signed Waiver of Liability, which holds our member harmless regardless of the appeal outcome. Form can be found at: https://www.cms.gov/Medicare/Appeals-and-Grievances/MMCAG/Downloads/Waiver-of-Liability-Notice.pdf