Get Adjustment Request Form - Kps Health Plans

Filling out the Adjustment Request Form for KPS Health Plans online can seem daunting, but with the right guidance, it can be a straightforward process. This guide will help you navigate each section of the form effectively, ensuring that you provide all necessary information accurately.

Follow the steps to fill out the Adjustment Request Form with ease.

1. Click the ‘Get Form’ button to access and open the Adjustment Request Form in the online editor.
2. Begin by entering the Health Plan name at the designated section. Ensure that you write the correct name to avoid processing delays.
3. In the 'Product' field, fill in the specific product associated with your claim. Double-check that this reflects the plan you are enrolled in.
4. Direct your attention to the 'Attention' field. Enter the name of the department or person responsible for processing the adjustment requests.
5. Enter the date you are preparing the cover sheet in the 'Date cover sheet prepared' field. This is essential for tracking and processing purposes.
6. Indicate that this is not a duplicate claim by confirming the checkbox stating, 'This is NOT a DUPLICATE claim.' This ensures your claim is sent to the right area for reprocessing.
7. Fill in the 'Original Claim Number' from your voucher. This allows the claims team to identify the previous claim being corrected.
8. Provide the name and phone number of the provider office contact person responsible for the claim. This ensures direct communication if necessary.
9. In the 'This claim is a corrected billing' section, check all applicable reasons that justify the correction. Provide specific details by selecting appropriate options, such as corrected diagnosis or charges.
10. If there are any specific clarifications or comments regarding the correction, enter them in the comment section provided.
11. Indicate whether supporting documentation is attached by checking 'Yes' or 'No.' Make sure to attach any required documents to support your adjustment request.
12. After completing all sections of the form, review your entries for accuracy. Once satisfied, save your changes, then download, print, or share the completed form as needed.

Take action today and fill out your Adjustment Request Form online for a seamless claims process.