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.
| Question | Answer |
|---|---|
| Form Name | Adjustment Request Form |
| Form Length | 1 pages |
| Fillable? | Yes |
| Fillable fields | 49 |
| Avg. time to fill out | 10 min 7 sec |
| Used by | Healthcare providers and billing staff |
| Purpose | Submit claim adjustments to MVP Health Care |
| Do not use for | Authorization denials or medical necessity appeals |
| Other names | cardinal innovations claim adjustment form, cair adjustment claim forms, mvp claim adjustment form, dc6 187 good adjustment transfer request form |