Provider Claims Appeals Process
State mandated requirements for appeal requests
New Jersey Public Law 2005 chapter 352, known as the Health Claims Authorization, Processing, and Payment Act (HCAPPA), allows a provider to submit a Health Care Provider Application to Appeal a Claims Determination for provider claim appeals.
To learn more about HCAPPA, professional providers should refer to their AmeriHealth New Jersey Provider Manual for Participating Professional Providers CD. Facility and ancillary providers should refer to the Hospital Manual for Participating Hospitals, Ancillary Facilities, and Ancillary Providers.
First-level provider appeal
Under HCAPPA, you as a provider may initiate a first-level provider appeal on or before the 90th calendar day following receipt of our claims determination. Submit your appeal by completing and mailing the appeal form and any additional relevant information in support of your appeal to the following address:
AmeriHealth New Jersey
Provider Claim Appeals Unit
P.O. Box 7218
Philadelphia, PA 19101
Fax to: 609-662-2480
Should you dispute our appeal determination, you may initiate an arbitration request through the New Jersey Program for Independent Claims Payment Arbitration (PICPA). You may request arbitration by completing the PICPA form within 90 calendar days of receipt of the appeal decision.
Appeal arbitration requests must meet the following criteria:
- Original appeal was filed on the proper form. You must have submitted your original (first-level) provider appeal on the Health Care Provider Application to Appeal a Claims Determination form.
- Payment amount in dispute is $1,000 or more. You may aggregate your own disputed claim amounts for the purposes of meeting the $1,000 threshold requirement.
- Dispute is not eligible to be appealed through other programs. PIPCA will not consider any dispute pertaining to medical necessity that is eligible to be submitted to the Independent Health Care Appeals Program.
If you have additional questions about initiating an appeal or arbitration request, contact:
- Customer Service at 1-888-YOUR-AH1
- Your Provider Partnership Associate.
For more information about the provider appeals and arbitration processes, contact: