![]() ![]() ![]() Our statement that we overpaid one or more claims is wrong, or that the amount we calculated as overpaid is wrong.We’ve failed to appropriately pay interest on the claim.You received appropriate authorization from us or another carrier for the services, but our determination notes we won’t pay because appropriate authorization is lacking.We’ve failed to adjudicate the claim, or an uncontested part of a claim, in a timely manner consistent with the law and the terms of the provider’s contract (if any). ![]() You can also submit this appeal form if you believe: Indicated that we need more substantiating documentation to support the claim and you believe the required info is inconsistent with our claims-handling policies and procedures or isn’t relevant to the claim.Resulted in the claim being paid at a rate you didn’t expect because of differences in our treatment of the codes in the claim compared to what you believe is appropriate.Resulted in the claim being paid at a rate you didn’t expect based on a contact with us or the terms of the member’s NJ Famil圜are (Medicaid) coverage.Resulted in the claim not being paid at all for reasons other than a utilization management (UM) determination or a determination of ineligibility, coordination of benefits or fraud investigation.You can submit this appeal form if our determination: To appeal, just use the Health Care Provider Application to Appeal a Claims Determination (PDF). Both in-network and out-of-network providers have the right to appeal our claims determinations within 60 calendar days of receipt of the claim denial. ![]()
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