Get Affinity Health Plan ...claim Adjustment Request Form Instructions ... - Affinityplan

The Claim Adjustment Request Form is essential for healthcare providers seeking adjustments on claims. This guide provides step-by-step instructions to assist you in accurately completing the form online.

Follow the steps to successfully fill out the Claim Adjustment Request Form.

1. Press the ‘Get Form’ button to access the Claim Adjustment Request Form and open it for editing.
2. In the section labeled 'Physician / Health Care Provider Name,' enter the name of your practice or facility as registered.
3. Fill in the 'Provider & TIN Number' with your Tax Identification Number accurately.
4. Complete the 'Billing Address' section, including the street address, city, state, and ZIP code.
5. Indicate the type of service by checking the appropriate box: Hospital, Physician/Ancillary, or Other (specify).
6. Input the claim number pertaining to your original claim; only one Claim Adjustment Request Form should be used per claim number.
7. Input the member’s name and their member ID number for reference.
8. Provide the date(s) of service for which the adjustment is being requested.
9. Clearly describe the reason for the adjustment request, including details of the previous underpayment or denial.
10. If submitting by mail, don’t forget to attach a copy of the Explanation of Payment (EOP) with your request.
11. Enter your name, contact phone number, and the date when you completed the Claim Adjustment Request Form.
12. Once you have filled out the form, save the changes and either download, print, or share the completed form as needed.

Complete your Claim Adjustment Request Form online today and ensure your claims are processed accurately.