If you have ever filed a claim with your insurance company, you may have had to fill out a claim adjustment request form. This form is used by the insurance company to determine how much of the claim they will pay and to collect any additional information needed to process the claim. In this blog post, we will discuss what information is required on a claim adjustment request form and offer some tips for completing the form accurately and efficiently. We hope this information will be helpful for you if you need to file a claim in the future.
Question | Answer |
---|---|
Form Name | Claim Adjustment Request Form |
Form Length | 1 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 15 sec |
Other names | Claim_Adj_Form mvp claim adjustment request form |
CLAIM ADJUSTMENT REQUEST FORM
Please attach a copy of this completed form when returning claims to MVP Health Care® for adjustments.
Check the box that best describes the purpose for submitting the Claim Adjustment Request Form and attachments. If you have questions about completing this form, please call the Customer Care Center for Provider Services
at
DO NOT USE THIS FORM TO SUBMIT APPEALS FOR:
No Authorization / Prior Authorization Obtained Before Service Rendered / Medical Necessity / Inpatient Hospital
Please submit one claim per adjustment form and do not highlight any fields on this form or any attachments.
An asterisk (*) denotes required information.
Today’s Date: ______________________________________________________________________________________
Document # (Claim #)* |
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Member ID* |
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Date of |
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Member |
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Provider |
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Service* |
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Name* |
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Name* |
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Provider |
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Provider |
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Tax ID* |
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ID# |
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NPI* |
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Contact Information |
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Name* |
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Phone* |
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Fax* |
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Coordination of Benefits Information |
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1. Alternate Insurance Information/EOB Coverage Attached |
2. |
3. |
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Adjustment |
Requested Documentation Enclosed |
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1. Surgical or Surgical Modifier |
4. Path/Rad Findings |
7. Transportation Run Record |
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10. Evidence of Qualifying Stay |
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2. Office Notes |
5. Code Review/Asst. Surg. |
8. Manufacturer’s Invoice |
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11. Second Level Clinical |
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3. Surgical/Operative Reports |
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9. Medical Record Review |
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Review |
Check Reason for Adjustment Request (please check only one):
Options
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Added/Deleted Charges |
5. Place of Service Correction |
10. |
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(Invoice Attached) |
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Date of Service Correction |
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Quantity Correction |
11. |
Provider Information Correction |
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Diagnosis Correction |
7. |
Copay/Deductible/Coinsurance Adjustment |
12. Referral or Prior Auth Now on File: |
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4. |
CPT/Modifier/ICD Procedure Code |
8. |
Timely Filing Issue |
#__________________________ |
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9. |
Duplicate Denial Error |
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Please note reason for adjustment or untimely filing, or note the rationale for modifier use:
Please return this completed form and any supporting documentation to: MVP Health Care
P.O. Box 2207
Schenectady, NY
For internal use only:
Revised 5/13