Important Information
All informal provider appeals should be submitted through the online Provider Inquiry Portal
located at Provider.HealthAlliance.org. See provider manual for appeals policy.
*Note: Equian, EquiClaim and Cotiviti retrospective audit appeals must be submitted directly to the vendor.
This form is to be used for claim denial appeal requests after you have exhausted all efforts of resolution
through the online post-service claim inquiry process for the following reasons only:
• Contractual allowances
• Medical necessity
• Clinical editing
• Prior authorization not obtained
If you are not satised with the outcome of the online post-service claim inquiry, you may submit an
appeal. The purpose of an appeal is to escalate an informal inquiry or bring immediate attention to a critical
issue. An appeal should not be the rst attempt at communication between the parties for any given issue.
You may only appeal for specic reasons outlined in your provider agreement such as contractual allowances,
medical necessity, investigational services, clinical editing or no prior authorization.
Appeal Reason
Medical Necessity
• Please include rationale, relevant medical record documentation and InterQual criteria to support
medical necessity.
Contractual Allowance
• Please provide the underpayment or overpayment amount and the expected reimbursement.
Clinical Editing
• Please submit documentation or literature from a nationally recognized organization such as
National Correct Coding Initiative (NCCI).
Note: Our code combinations or bundles are performed in our clinical editing system and are
supported by nationally recognized criteria.
Provider Appeal Form
Date: Organization or Provider Name:
Contact Name: Member Name:
Contact Email: Member ID:
Contact Phone #: Date(s) of Service:
Portal Inquiry Reference #: Claim #:
Prior Authorization Denial
• Please provide a detailed explanation of why prior authorization was not submitted or submit
documentation on why authorized procedure was not updated within the 7 day time frame.
Provider Appeal
• Health Alliance Medical Plans must receive the appeal within 90 days from original denial.
Documentation Needed for Appeal
• Appeal form
• An explanation of why you disagree with the claim denial and how you believe Health Alliance
should resolve the issue.
• Supporting documentation such as relevant medical records, operative reports and ofce notes.
Explanation of Dispute
Claim Disputes
Health Alliance Medical Plans has two levels of review when providers appeal a denied claim:
provider inquiry and provider appeal.
Step 1: Provider Inquiry Portal – We will attempt to resolve provider-initiated inquiries through
the course of normal operational interactions and Health Alliance Medical Plans’ informal inquiry
resolution process. Providers must initiate informal inquiries within 90 days of the original denial.
To clarify, we dene provider inquiries as the rst contact initiated by the provider to
Health Alliance. We accept inquiries through our provider inquiry portal.
Step 2: Provider Appeal – If a provider is dissatised with a claims processing or
administrative determination and has not found satisfactory resolution through the provider
inquiry portal process, the provider may submit an appeal to Health Alliance within
90 days from the original denial.
We dene appeals as written provider correspondence about a claim issue previously reviewed
through the inquiry process, yet still unresolved to the provider’s satisfaction. All appeals must
have valid reasons for consideration as stated in your provider agreement. Appealable issues
include, but are not limited to, allowances, medical necessity and clinical editing.
Documentation Needed for Appeals
Appeal form
An explanation of why you disagree with the claim denial and how you believe
Health Alliance should resolve the issue.
Supporting documentation such as relevant medical records, operative reports and
ofce notes.
PHPNHA21-ProviderAppealNoIUOfm-0621
