Get Provider Adjustment Request Form - Peach State Health Plan

Completing the Provider Adjustment Request Form for Peach State Health Plan can be straightforward when following the right steps. This guide provides clear instructions to help you fill out the form accurately, ensuring that your adjustment request is processed smoothly.

Follow the steps to effectively fill out the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the provider name in the designated field. This should be the name under which your practice operates.
3. Next, input your provider number, which is assigned to you by the health plan. Ensure accuracy to avoid processing delays.
4. Fill in the control number associated with the claim you are requesting to adjust. This number helps identify your specific case.
5. In the date(s) field, include the relevant dates found on your explanation of payment (EOP) statement directly beneath the patient name.
6. Provide the member's name and member number in the respective fields. This information links the adjustment request to the correct member's account.
7. Select the reason for the adjustment request by checking the appropriate box. If the reason is 'other', please provide a detailed explanation.
8. If you are submitting a batch of similar or like claims for adjustment, complete the relevant fields for batch submission, indicating the number of claims and control claim numbers.
9. In the section that asks for an explanation of the issue, provide a detailed description of the circumstances surrounding your adjustment request.
10. If a correction is needed, circle the claim number on the EOP, and attach a new CMS 1500 or UB 04 marked 'RESUBMISSION' as required.
11. Once all fields have been completed, review the information for accuracy. You can then save changes, download the form, print it, or share it as needed.

Take action now and complete your Provider Adjustment Request Form online to facilitate timely processing of your adjustment requests.