Get Acrobat - Indianamedicaid .com

This guide provides a comprehensive overview of how to accurately complete the Acrobat - Indianamedicaid .com form. With step-by-step instructions, users will be able to navigate the online form efficiently, ensuring all necessary information is provided for a successful request.

Follow the steps to complete your adjustment request form.

1. Press the ‘Get Form’ button to access the adjustment request form and open it in your document management system.
2. Enter the provider NPI or LPI alongside your service location in the designated field to identify your practice.
3. Select the reason for adjustment by checking the appropriate box. This helps clarify the nature of the request.
4. Fill in the provider name, address, and ZIP+4 code for accurate identification.
5. Provide the provider's taxonomy code, which classifies the type of service being billed.
6. Enter the phone number of the contact person to ensure communication during the adjustment process.
7. Input the claim number (ICN) which can be found on the remittance advice associated with the claim.
8. Provide the member ID number, ensuring it is accurate and properly formatted.
9. Specify the date of service by entering both the 'From' and 'Thru' dates.
10. Enter the name of the member, ensuring the spelling is correct for effective processing.
11. Input the amount paid as listed on the original claim.
12. Provide the remittance advice date, indicating when the claim was paid.
13. Offer a detailed explanation of the adjustment or refund request, ensuring clarity.
14. Select the type of adjustment from the given options: underpayment, overpayment, or refund.
15. Indicate the claim type by checking the relevant box that corresponds to the claim in question.
16. Specify the program associated with the claim to ensure proper routing of the adjustment request.
17. If applicable, enter the line number of the data needing correction. For information with no specific line number, enter zero.
18. Provide a description of the information to be corrected, maintaining accuracy in detail.
19. Input the current information as stated on the original claim for comparison purposes.
20. Enter the correct information that you would like the claim adjusted to reflect.
21. Make sure to include the rendering NPI and taxonomy code as required.
22. Obtain a signature from an authorized individual such as a physician or billing clerk.
23. Finally, provide the date on which the adjustment request is submitted.
24. Review all provided information for accuracy and completeness before finalizing.
25. Once completed, save the changes, download a copy, print, or share the form as required.

Complete your adjustment request form online today to ensure a smooth processing experience.