(These guidelines do not apply to corrected claims submitted within the original 180 day claim filing limit.  These are not considered appeals and can be submitted directly to HNE's Claims Dept.)

Provider Appeal Guidelines:

A provider has the right to file a Provider Appeal if they disagree with how HNE has processed a claim.

A Provider Appeal must be submitted on the Provider Appeal Review Sheet.  This sheet can be found under Provider Forms on the HNE website (hne.com) or in the HNE Provider Manual.

The Health New England EOP and all supporting documentation including operative and or office notes, authorizations, invoices, or other information which would be pertinent to the review process, must be included.

Provider Appeals must be submitted within one year from the date of service.  Any requests submitted after the one year deadline will be denied.

Appeal Types:

Provider Contractual Appeals, such as:

• Claim denied for no authorization (when referral is required)
• Claim denied past filing limit
• Claim denied as billed incorrectly
• Claim denied as duplicate claim
• Claim reimbursement issue, e.g. CPT code(s), disagreement about payment methodology

Provider Adverse Determinations (relates to decisions made during the precertification process that impact how a claim has been processed), such as:

• Claim denied for no authorization (when preauthorization is required)
• Claim denied for not medically necessary
• Claim denied as experimental/investigational

PLEASE NOTE: If your appeal is regarding a denial of a Prior Approval Request Form and the service has not yet been rendered, your appeal will be treated as a member appeal and processed in accordance with HNE's member appeal guidelines.

RETURN TO FORMS