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Provider Claim Appeals Process (NJ Only)

State mandated requirements for appeal requests

In 2006, the New Jersey Senate Bill (SB) 2824, known as the Health Claims Authorization, Processing, and Payment Act (HCAPPA) requires a provider to submit a Health Care Provider Application to Appeal a Claims Determination form for all provider claim appeals.

To learn more about HCAPPA, professional providers should refer to their AmeriHealth 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

Appeal Arbitration

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.

For Questions and more Information

If you have additional questions about initiating an appeal or arbitration request, contact:

  • Customer Service at 1-800-275-2583, select prompt 2 for Provider Services;
  • your Network Coordinator or Hospital/Ancillary Services Coordinator.

For more information about the provider appeals and arbitration processes, contact:

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