Provider Administrative Appeal Form

Have you requested an Adjustment or a Reconsideration Request?*
Have you requested an Adjustment or a Reconsideration Request? *
- Yes
- No
You must submit the appropriate Adjustment or Reconsideration Request before you can submit an Administrative Appeal. Please see the form finder in the provider section of our website https://www.nhpri.org for assistance on the appropriate process.

Participating Status*
Participating Status *
- I am a Participating Provider
- I am not a Participating Provider
Member Information
Enter Member ID and Date of Birth to validate Member before proceeding with the form.
Member ID*
Member DOB*
MM slash DD slash YYYY
Date of Service Start*
MM slash DD slash YYYY
Date of Service End*
MM slash DD slash YYYY
Member Name*
First Last
Error Message
Claim number*
Provider Information
Group Billing NPI*

10 digits
Group Billing Name*
Error Message
Contact Name*
Contact Email*
Phone Number*
Description*
File Upload. Administrative Appeal requests with claims attached will be returned to the sender*
Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 24 MB.
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Member Information