Get South Carolina Claim Adjustment Form 130

This guide provides clear instructions for individuals who need to complete the South Carolina Claim Adjustment Form 130 online. By following these steps, users can ensure that they accurately fill out the form for claim adjustments.

Follow the steps to fill out the form effectively.

1. Click ‘Get Form’ button to access the form and open it in your preferred online editor.
2. Enter the provider name in the designated field using black or blue ink.
3. Provide the complete provider address, including city, state, and zip code.
4. List the total paid amount on the original claim.
5. Fill in the original CCN (Claim Control Number) in the corresponding field.
6. Enter the NPI (National Provider Identifier) as required.
7. Include the provider ID in the relevant section.
8. Input the recipient ID, ensuring the accuracy of the information.
9. Specify the originator of the claim in the designated field.
10. Select the adjustment type by ticking the appropriate box, choosing from options such as Void, Voiding/Replacing, DHHS, and others.
11. Indicate the reason for adjustment by filling in one option from the provided list.
12. Complete the comments section as needed for additional clarification.
13. Sign and date the form in the required fields.
14. Provide a contact phone number for follow-up queries.
15. After completing all sections, save your changes, and utilize the option to download, print, or share the filled form.

Begin filling out your South Carolina Claim Adjustment Form 130 online now.