In the complex realm of healthcare billing, especially when dealing with workers' compensation claims, navigating the process of adjusting a bill can be challenging. This is where the F245 183 000 form, officially known as the Provider’s Request for Adjustment, comes into play. It serves as a crucial tool for healthcare providers to request adjustments on bills submitted to the Department of Labor and Industries. Whether due to a full or partial overpayment or underpayment, this form allows for the correction of bill details including the worker's name, claim number, provider number, and specific information about the items or services billed, such as dates of service, types of service (TOS), procedure codes, and charges. The form requires detailed justification for the adjustment, supported by attaching necessary documentation. It's important to note that this form should not be used in situations where the bill was denied in full; instead, a new bill should be submitted. The form not only facilitates the adjustment process but also demonstrates the Department's efforts to streamline healthcare billing corrections, ensuring providers are fairly compensated for their services and that errors can be rectified promptly. Understanding and correctly completing the F245 183 000 form is integral for healthcare providers who navigate the intricacies of workers' compensation claims.
| Question | Answer |
|---|---|
| Form Name | Form F245 183 000 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | F245 183 000 f245 183 000 form |
Department of Labor and Industries
PO Box 44269
Olympia WA
Provider’s Request for Adjustment
•Submit one form for each ICN. Enter the information you want changed.
•Attach required reports and/or other documentation necessary to support your request.
•If your bill was denied in full, don’t use this form. Submit a new bill.
•See complete instructions on the next page.
Reason for adjustment:
Total/partial overpayment |
Partial underpayment |
Bill information:
Worker’ name (last name, first name)
Claim number
L&I provider number or NPI
Provider name
ICN on remittance advice
Information to be changed:
Line |
To/from date |
P |
T |
item |
of service or |
O |
O |
no. |
covered dates |
S |
S |
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Procedure |
Code |
ICD code |
code/revenue |
mod |
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code/NDC |
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Tooth no. |
Charge |
Days/ |
Days |
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units/ |
supply |
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qty |
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Description
Reason for adjustment:
Example: 2 units were billed in error; should have billed 6 units.
Signature:
Print name |
Signature |
Phone number |
Date |
Instructions for completing the Provider’s Request for Adjustment
Reason for Adjustment
Select reason for submitted adjustment.
Total/partial |
A total overpayment is when the entire bill was paid in error. |
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overpayment |
A partial overpayment is when a portion of the bill was overpaid. |
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You have two options to return the money to the department. |
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1. |
Complete and submit this form and the department will deduct the |
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overpayment from your future payments. |
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2. |
You may repay the money to the department. Send your check with the a |
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copy of the remittance advice to: |
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Department of Labor and Industries |
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Cashiers Office – MIPS Deposit |
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PO Box 44835 |
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Olympia WA |
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Underpayment |
Complete an Adjustment Request for each ICN that you think was underpaid with |
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the correct information for the procedures/items. Attach any required reports and/or |
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other documentation to support your request. |
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Bill information: |
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Worker’s name |
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Enter the worker’s name in the last name, first name, middle initial |
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format. |
Claim number |
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Enter the claim number for the worker. The claim number can be |
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found in the Claim Number column of the remittance advice. |
Provider’s name |
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Enter the name of the provider who performed the services. |
L&I provider number or NPI |
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Enter the L&I provider number or NPI for the provider who performed |
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the services. |
ICN |
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Enter the |
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advice for the procedure/item you are adjusting. |
Information to be changed: |
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Line item no. |
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Enter the line item number(s) from your original bill that you want to |
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correct. |
To/from date of service or covered |
Date of service, to and from date if date span, or admit and |
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dates |
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discharge date for hospital bills. |
POS |
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TOS |
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Procedure code/revenue code/NDC |
Enter the correct procedure, hospital service, or national drug code. |
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Code mod |
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Enter the correct modifier used to identify special circumstances for a |
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procedure or service. |
ICD code |
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Enter the ICD code for condition treated. Enter side of body if |
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applicable. |
Tooth no. |
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For dental services only. Enter the |
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number for the specific tooth number treated. |
Charge |
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Total charge for services provided for this line only. |
Days/units/quantity |
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Total days stayed for hospital accommodation codes, units of service |
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for procedure (time units, miles, etc), or number of items (tablets, |
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milliliters, etc). |
Days supply |
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For pharmacy services only. Total number of days a prescription is |
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intended to cover. |
Description |
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Description of the procedure or services provided. |