Claim Adjustment Request Form – Fill Out and Use This PDF

Claim Adjustment Request Form PDF Details

The Claim Adjustment Request form serves as a critical tool for health care providers seeking adjustments on claims with MVP Health Care®. It is required for providers to attach a completed copy of this form alongside any claims they wish to have adjusted. The form comprises several sections, including checking boxes that indicate the reason for the adjustment request, essential contact information, and specific instructions for different types of adjustments like documentation for alternate insurance information or proof of medical necessity. Providers are advised to submit one claim per adjustment form and to avoid highlighting any parts of the form or attachments. Accurate completion of the form is paramount, emphasizing the need to fill out required fields marked with an asterisk (*), such as Claim Number, Member ID, Date of Service, Provider Name, and Tax ID, among others. It also delineates clear instructions not to use this form for appeals relating to issues like no authorization, prior authorization, medical necessity, or inpatient hospital services. Further, it provides guidance on how to direct appeals and whom to contact for assistance, indicating two different phone numbers for providers in different regions. By specifying what documentation to include for various adjustment requests, such as surgical reports, office notes, or evidence of a qualifying stay, the form facilitates a streamlined process for both the provider submitting the request and MVP Health Care® in reviewing and processing these adjustments.