What Is the Adjustment Request Form?

The Adjustment Request Form helps healthcare providers correct claims filed with MVP Health Care. Common reasons include changes to dates of service, procedure codes, diagnosis codes, or billing amounts.

Submit one claim per adjustment form and do not highlight any fields. Sections marked with an asterisk are required. Select the reason for your adjustment from the options listed before completing the remaining fields.

Attach a corrected UB-04 or CMS-1500 form when submitting billing corrections. For coordination of benefits adjustments, include the other carrier's explanation of benefits. Use the Health Insurance Appeal Form for authorization denials rather than this adjustment form.

Mail the completed form with all supporting documents to the MVP Health Care address listed on the form. Do not submit appeals related to medical necessity using this adjustment form.

QuestionAnswer
Form NameAdjustment Request Form
Form Length1 pages
Fillable?Yes
Fillable fields49
Avg. time to fill out10 min 7 sec
Used byHealthcare providers and billing staff
PurposeSubmit claim adjustments to MVP Health Care
Do not use forAuthorization denials or medical necessity appeals
Other namescardinal innovations claim adjustment form, cair adjustment claim forms, mvp claim adjustment form, dc6 187 good adjustment transfer request form

How to Edit Adjustment Request Form Online for Free

Follow these steps to complete your adjustment request for MVP Health Care.

  1. Identify the reason. Select the correct reason code on the form, such as date of service correction, procedure code change, diagnosis correction, or coordination of benefits.
  2. Complete required fields. Fill in all fields marked with an asterisk, including the provider NPI, patient name, claim number, and service date.
  3. Attach supporting documents. Include a corrected UB-04 or CMS-1500 for billing corrections, or the other carrier's explanation of benefits for coordination of benefits issues.
  4. Submit one claim per form. Each adjustment must be on a separate form. Do not combine multiple claims on one submission.
  5. Mail to MVP Health Care. Send the completed form and attachments to the appropriate address shown on the form.

View related forms: CMS-1450 Claim Form, Medical Claim Form, and Aetna Appeal Form.

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