Form Hca 15 – Fill Out and Use This PDF

Form Hca 15 is an essential part of the process to officially document and manage work duties, skills, performance reviews and expectations on the job. The documentation that it provides ensures factors such as attendance, task completion and experiences in problem solving can be tracked over time. It gives insight into how to best evaluate job criteria as well as recognizing possible areas for improvement after examining recorded productivity levels and accountabilities. Companies who emphasize streamlined processes often depend on Form Hca 15 for making more efficient decisions about employee expectations, compliance standards and other important transactional information. Therefore, having this electronic fillable form at their disposal can provide an accurate addition to any HR focused job application which requires great detail when attempting to hire or terminate someone on staff.

Form Hca 15 PDF Details

This form is for individuals who are not U.S. citizens or permanent residents and are requesting an exemption from the individual shared responsibility payment for not having insurance. This form is also used to request an exemption from the shared responsibility payment for certain situations, such as not being able to afford coverage or belonging to a religious sect with objections to health insurance. Read on to learn more about Form Hca 15 and how to submit it. If you are not a U.S. citizen or permanent resident, and you do not have insurance, you may have to pay a penalty called the individual shared responsibility payment. However, there are some situations where you can exempt yourself from this penalty. For example, if you cannot afford coverage or if you belong to a religious sect that objects to health insurance. You can apply for an exemption by submitting Form Hca 15 . In this article, we will discuss who should use this form and how to complete it properly. So keep re

Question	Answer
Form Name	Form Hca 15
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	hca 15 oklahoma healthcare authority form

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	CMS-1500, DENTAL, CROSSOVER PART B PAID CLAIM ADJUSTMENT REQUEST
	Mail completed requests to: OHCA - Adjustments, 4345 N. Lincoln Blvd., Oklahoma City, OK 73105
	Mail Refunds to: OHCA- Finance, P.O. Box 18299, Oklahoma City, OK 73154-0299

1) PROVIDER NUMBER:		(2) REASON FOR
		ADJUSTMENT: (Check appropriate
		Box)
PROVIDER NAME/ADDRESS:		Box)
PROVIDER NAME/ADDRESS:		a Change TPL Amt. (Attach all EOMB’s that apply)
		a Offset or Refund of entire claim amount
		(check block 10 )
PHONE NUMBER:		a Change information as indicated in blocks 13-16

CONTACT PERSON:		a Medicare Adjustment ( Attach all EOMBs that apply to
		this adjustment )

(3) CLAIM NUMBER ( ICN )	(4)CLIENT ID NO.		(5) DATE OF SERVICE
			From:	Thru:

(6) CLIENT NAME		(7) AMOUNT PAID	(8) REMITTANCE ADVICE DATE

(9) GIVE COMPLETE EXPLANATION OF		ADJUSTMENT OR REFUND REQUEST:

(10)TYPE OF ADJUSTMENT a Underpayment Adjustment

Overpayment Adjustment (Deduct from from future payments) a Refund Adjustment (Check attached)

Check number:

(11) CLAIM TYPE		(12) MEDICAID PROGRAM
a	Dental	Fee for Service
a	Crossover	SoonerCare
	CMS-1500

LIST THE INFORMATION TO BE CORRECTED IN THE BLOCKS BELOW. IF NO LINE NO. IS ASSOCIATED WITH THE CORRECTION, ENTER A ZERO (0) IN THE LINE NUMBER FIELD. (i.e. TPL APPLIED WOULD ALWAYS BE LINE # 0.)

(13) LINE NO.

(14)DESCRIPTION OF INFORMATION TO BE

CORRECTED

(15)

CURRENT

INFORMATION

(16)

CORRECTED

INFORMATION

17) SIGNATURE: _________________________________________________ (18) DATE: _____________________

OHCA Revised 09/03/2014

HCA-15 (p1)

STATE OF OKLAHOMA

OKLAHOMA HEALTH CARE AUTHORITY

CMS-1500, DENTAL, CROSSOVER PART B PAID CLAIM ADJUSTMENT REQUEST

INSTRUCTIONS

A completed adjustment request form is required for each claim you are requesting to be adjusted. In addition, a copy of the Remittance Advice and a copy of the corrected claim will also facilitate the adjustment process. If the adjustment request is for a Crossover claim attach a copy of the Medicare EOMB or if the request is for an adjustment to the TPL amount attach a copy of the insurance EOMB.

1PROVIDER NUMBER

PROVIDER NAME/ ADDRESS PHONE NUMBER

CONTACT NAME

2REASON FOR ADJUSTMENT

3CLAIM NUMBER

(ICN)

4CLIENT ID NO.

5DATES OF SERVICE

6CLIENT NAME

7AMOUNT PAID

8REMITTANCE ADVICE DATE

9EXPLANATION

10TYPE OF ADJUSTMENT

11CLAIM TYPE

12PROGRAM

13LINE NO.

14DESCRIPTION

15CURRENT INFO

16CORRECTED INFO

17SIGNATURE

18DATE

Enter your 9 digit billing provider number and 1 character service location

Enter your current billing name and address

Enter phone number of contact person

Enter a contact name

Check the appropriate box for the reason you are requesting an adjustment

Enter the Internal Control Number of the claim you wish to adjust. This can be found onthe Remittance Advice. (Use the most current ICN for the claim to be adjusted.)

Enter the recipient’s 9 digit identification number

Enter the From and Thru Dates of Service as billed on the claim

Enter the First and Last Name of the Recipient

Enter the Paid Amount of the claim to be adjusted

Enter the date of your Remittance Advice on which the claim last paid

Give a clear explanation for the requested adjustment or refund

Check the appropriate box for the type of adjustment you are requesting:

*Underpayment – An adjustment to a claim in which you are requesting additional payment, or for which you are requesting a change to the claim’s data which will result in no net change in payment.

*Overpayment – An adjustment to a claim for which you are requesting that an overpaid amount be deducted from your future payments. (This may be a recoupment of a portion of the claim or the entire amount of the claim.)

*Refund – Same as overpayment except that you are submitting a refund check for the overpaid amount. (A refund may be applied to a portion of the claim or to the entire amount of the claim.)

Check the appropriate box of the claim type to be adjusted.

Check the appropriate box of the program to which the claim to be adjusted is associated.

Enter the number of the line that data is to be adjusted. If the adjusted data is not associated to a specific line on the claim, enter a zero (0) in this field

Enter a brief description of the data that is to be corrected on the claim

Enter the information as stated on the current claim that is to be adjusted

Enter the corrected information for the claim

Enter signature of appropriate person (physician, billing clerk, etc. – not required)

Enter the date you are submitting this request (Required)

OHCA Revised 09/03/2014

HCA-15 (p2)

How to Edit Form Hca 15 Online for Free

Form Hca 15 can be filled in without any problem. Just make use of FormsPal PDF tool to complete the job promptly. To make our tool better and easier to use, we constantly develop new features, bearing in mind feedback coming from our users. To begin your journey, consider these easy steps:

Step 1: Click on the "Get Form" button above. It is going to open up our editor so that you could start filling out your form.

Step 2: Using our online PDF editor, you'll be able to do more than merely fill out blank fields. Try all of the features and make your docs seem professional with custom textual content added, or optimize the original content to perfection - all that comes along with the capability to incorporate just about any photos and sign it off.

With regards to the fields of this particular document, this is what you should do:

1. You will need to fill out the Form Hca 15 correctly, so be mindful while filling out the parts containing all these blank fields:

2. Once your current task is complete, take the next step – fill out all of these fields - TYPE OF ADJUSTMENT a Underpayment, CLAIM TYPE a Dental a Crossover, CMS, MEDICAID PROGRAM, Fee for Service SoonerCare, LIST THE INFORMATION TO BE, LINE NO, DESCRIPTION OF INFORMATION TO BE, CORRECTED, CURRENT, INFORMATION, CORRECTED INFORMATION, SIGNATURE DATE, OHCA Revised, and HCA p with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Be very attentive when filling out CMS and CLAIM TYPE a Dental a Crossover, because this is where a lot of people make mistakes.

Step 3: Once you have glanced through the details in the fields, click "Done" to complete your form. Sign up with us today and easily use Form Hca 15, available for download. Each and every modification made is handily kept , making it possible to change the pdf further if necessary. We do not share or sell any information that you type in whenever dealing with forms at our site.

Form Hca 15 – Fill Out and Use This PDF

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