CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Appeal process and timelines

Governs internal and external appeal filing windows and decision timelines for multiple Lines of Business (Medicaid, HBE, MMP Parts B/C/D, Provider Claim Disputes) for Neighborhood Health Plan of Rhode Island members and providers.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAppeal process and timelines

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders must submit an Appointment of Representative form when filing appeals on behalf of a member; absence will result in dismissal.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

60dMedicaid internal appeal filing window

180dHBE internal appeal filing window

65dMMP Part C/B filing window

60dProvider claim dispute filing window

72hrExpedited decision timeframe

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Appeals: Filing Windows and Decision Timelines

Appeal timelines and next-level instructions

Internal appeal filing windows, decision timeframes, and next-level instructions by Line of Business.

ALL of the following

Medicaid - Internal appeal filing: 60 calendar days from decision (one internal appeal level).
Medicaid - Internal appeal decision timeframes: expedited = 72 hours; standard = 30 days.
Medicaid - Next-level options: request external appeal within four (4) months of appeal denial letter and/or request a State Fair Hearing within 120 calendar days of appeal denial letter.

ALL of the following

HBE - Internal appeal filing: 180 calendar days from decision (one internal appeal level).
HBE - Internal appeal decision timeframes: medical expedited = 72 hours; pharmacy expedited = 24–72 hours per OHIC; standard = 72 hours to 30 days.
HBE - Next-level options: request external appeal within four (4) months of appeal denial letter. Members must include a $25 check or money order payable to Neighborhood Health Plan of Rhode Island to satisfy their share of external filing fees.

ALL of the following

MMP Part C - Internal appeal filing: 65 calendar days from decision (one internal appeal level).
MMP Part C - Internal appeal decision timeframes: expedited = 72 hours; standard = 30 days.
MMP Part C - Next-level options: for Medicare-only and overlap services, appeals upheld by GAU are auto-forwarded to MAXIMUS; members may request external appeal within four (4) months of appeal denial letter and/or request a State Fair Hearing within 120 calendar days of appeal denial letter.

ALL of the following

MMP Part B (Pre-Service) - Internal appeal filing: 65 calendar days from pharmacy decision letter.
MMP Part B (Pre-Service) - Internal appeal decision timeframes: expedited = 72 hours; standard = 7 days.
MMP Part B (Pre-Service) - Next-level handling: all Part B appeals are auto-forwarded to MAXIMUS if upheld by GAU.

ALL of the following

MMP Part D (handled by CVS Caremark) - Internal appeal filing: 65 calendar days from decision.
MMP Part D - Internal appeal decision timeframes: expedited = 72 hours; standard = 7 days.
MMP Part D - Next-level instructions: member or provider must request external appeal directly with MAXIMUS within 60 calendar days of the appeal denial letter.

ALL of the following

Provider Claim Disputes - Internal appeal filing: 60 calendar days from date of claim/recoup denial (unless provider contract specifies 365 days).
Provider Claim Disputes - Internal appeal decision timeframe: 60 days.
Provider Claim Disputes - Next-level: one internal level only (no further internal levels).

General note: External appeal process is available only when a clinical decision is rendered at the internal appeal level.

Codes and Provider Claim Timelines

No codes specifiedmixed

Provider claim dispute decision timeframe

Decision timeframe60 Days from date of claim/recoup denial

Filing window60 calendar days from date of claim/recoup denial (unless provider contract states 365 days)

Internal appeal levelsOne level of internal appeal for provider claim disputes

Filing Requirements and Appointment of Representative

Documentation Required

Appointment of Representative Required

If an appeal is submitted by anyone other than the member, the member's legal representative (with legal documentation on file), or the treating physician, an Appointment of Representative (AOR) is required. GAU will send the appropriate AOR form to the member. If the required AOR form is not returned or the member does not respond to requests for the form, the appeal will be dismissed.

AOR required when appeal submitted by third party (non-member, non-legal rep on file, non-treating physician).
GAU sends AOR form to the member; provider/third-party must ensure member completes and returns it.
Failure to provide a completed AOR or failure to respond to GAU requests will result in dismissal of the appeal.

Billing Rule

Provider Claim Dispute Filing

Key Terms and Abbreviations

External Appeal

DefinitionAn External Appeal is the qualified next‑level review available when a clinical decision is rendered on the Internal Appeal level; members may request an external appeal within four (4) months of the Internal Appeal denial in most LOBs.

When availableOnly available when a clinical decision is rendered on the Internal Appeal level (applies to all LOBs).

Filing timeframe (general)Request external appeal within four (4) months of the Internal Appeal denial letter for applicable LOBs; some LOBs (e.g., Part D) have specific instructions/shorter windows.

Appointment of Representative (AOR)

DefinitionAppointment of Representative (AOR) is legal documentation that authorizes someone other than the member, their legal representative, or their treating physician to submit an appeal on the member’s behalf.

Requirement