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Get Provider Claim Adjustment Request Form - Mhs Indiana
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How to fill out the Provider Claim Adjustment Request Form - MHS Indiana online
This guide provides a clear and comprehensive approach to completing the Provider Claim Adjustment Request Form for Managed Health Services in Indiana. By following these steps, you can efficiently request adjustments for any claims that do not match your expected payments.
Follow the steps to fill out your form easily and accurately.
- Click ‘Get Form’ button to access the Provider Claim Adjustment Request Form and open it in your online editor.
- Fill in the required information in the designated box at the top of the form. This includes providing your provider name, provider tax identification number, control number, date(s) of service, member name, and member RID number.
- Select the reason for your adjustment request by checking the appropriate box. If your reason is different from the listed options, please provide a detailed explanation in the space provided.
- Complete the date of request, requestor name, and requestor phone number fields.
- Attach a copy of the Explanation of Payment (EOP) for the claim(s) that you seek to adjust. Ensure that the relevant claims are clearly circled.
- If corrections are needed for procedure codes, location codes, or modifiers, include a copy of the EOP page with the claim circled, along with a new, corrected CMS-1500 or UB-04 form marked 'RESUBMISSION' at the top.
- Once all information is complete and attached documents are prepared, save any changes made to your form, and then proceed to download, print, or share the form as needed.
Take action today and submit your adjustment request online for faster processing!
You can find your MHS provider by visiting the MHS Indiana website and using their provider search tool. You can also contact MHS customer support for help in locating a provider that meets your needs. If you have any concerns regarding your current provider, reference the Provider Claim Adjustment Request Form - MHS Indiana for assistance.