[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-194430-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-194430-en":127},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","na-care-provider-appeals-form-2026-r","NA Care Provider Appeals Form 2026 R","","This document outlines the NA Care Provider Appeals Form for 2026, with the identifier R. It provides definitions for \"Claim Appeal/Reconsideration\" and \"Claim Dispute,\" clarifying the processes for members, representatives, or providers to request a review of an adverse initial determination made by a health plan. The form requires specific provider information, including Name, Tax ID, and NPI, alongside member details such as Name, Member ID, and Date(s) of Service. Crucially, claim information such as the Claim number and the Date of the last Explanation of Payment (EOP) must be included. The reason for the request needs a detailed explanation, with applicable authorization numbers if relevant. The form also designates a point of contact for the provider, including their name and number, to address any inquiries or requests for further information. It emphasizes adhering to specific time frames and deadlines for submitting appeals, reconsiderations, and disputes, which are mandated by regulations or specific contract terms from the date of the original Explanation of Benefits (EOB) or denial. Providers are advised to consult their Provider Manual for precise time frame details.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/na-care-provider-appeals-form-2026-r/194430/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/na-care-provider-appeals-form-2026-r/194430.png","ImageObject",442,249,{"name":42,"@type":43},"Gelato","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-08","2026-09-03",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",10,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What is a Claim Appeal/Reconsideration?","Question",{"text":63,"@type":64},"A Claim Appeal/Reconsideration is a review requested by a member, representative, or provider in response to an adverse initial determination made by the health plan. This process is governed by applicable regulations and provider contracts.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What information is required to submit the NA Care Provider Appeals Form?",{"text":68,"@type":64},"To complete the request, providers must submit Provider Information (Name, Tax ID, NPI), Member Information (Name, Member ID, Date(s) of Service), Claim Information (Claim number, Date of last EOP), and a detailed Reason for Request, including any applicable authorization numbers. A contact name and number for questions are also required.",{"name":70,"@type":61,"acceptedAnswer":71},"What are the time frames for submitting appeals or disputes?",{"text":72,"@type":64},"Appeals, reconsiderations, and disputes must be submitted according to regulations or specific contract terms from the date of the original Explanation of Benefits (EOB) or denial. Providers should refer to their Provider Manual for specific time frames.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},194430,1788439102,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,123],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":30,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":80,"read_time":22},19241457091524,"https://us-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c","| | Definitions\u003Cbr>• Claim Appeal/Reconsideration: A review requested by a member, a member’s representative, ora provider (to the extent permitted by applicable regulations & their provider contract) in response to an adverse initial determination made by the health plan.\u003Cbr>• Claim Dispute: A review in response to an adverse initial determination made by the health plan regarding payment of a claim, requested by a provider who is not entitled to a regulated appeals process by federal/state mandate or by their provider contract. |\n| --- | --- |\n| | When submitting this form fill out the following information to complete the request:\u003Cbr>• Provider Information: Name, Tax ID, and NPI.\u003Cbr>• Member Information: Name, Member ID, Date(s) of Service.\u003Cbr>• Claim Information: Claim number, Date of last Explanation of Payment (EOP) .\u003Cbr>• Reason for Request: Explanation of reason for request, including applicable authorization numbers if applicable.\u003Cbr>• Provider’s contact name and number for any questions or further information. |\n| | Time Frames and Deadlines\u003Cbr>• Appeals/reconsiderations and disputes must be submitted as required by regulations or specific contract from the date of the original Explanation of Benefits (EOB) or denial. Please refer to your Provider Manual for specific time frames. |\n| (continued) |  |","cbCaiksZYWTOOnHf","https://ap.wps.com/l/cbCaiksZYWTOOnHf","pdf",91695,"English","# Definitions\n## Claim Appeal/Reconsideration\n## Claim Dispute\n# Form Submission Requirements\n# Time Frames and Deadlines","[{\"question\":\"What is a Claim Appeal/Reconsideration?\",\"answer\":\"A Claim Appeal/Reconsideration is a review requested by a member, representative, or provider in response to an adverse initial determination made by the health plan. This process is governed by applicable regulations and provider contracts.\"},{\"question\":\"What information is required to submit the NA Care Provider Appeals Form?\",\"answer\":\"To complete the request, providers must submit Provider Information (Name, Tax ID, NPI), Member Information (Name, Member ID, Date(s) of Service), Claim Information (Claim number, Date of last EOP), and a detailed Reason for Request, including any applicable authorization numbers. A contact name and number for questions are also required.\"},{\"question\":\"What are the time frames for submitting appeals or disputes?\",\"answer\":\"Appeals, reconsiderations, and disputes must be submitted according to regulations or specific contract terms from the date of the original Explanation of Benefits (EOB) or denial. Providers should refer to their Provider Manual for specific time frames.\"}]","NA Care Provider Appeals Form 2026 R | PDF"]