Get Physician/provider Claim Adjustment Request Form - Blue Cross ...

This guide provides clear, step-by-step instructions on completing the Physician/Provider Claim Adjustment Request Form for Blue Cross. Whether you are a healthcare professional or administrative staff, this document is designed to be user-friendly and supportive.

Follow the steps to successfully complete the request form.

1. Press the ‘Get Form’ button to access the Physician/Provider Claim Adjustment Request Form and open it in your preferred editing tool.
2. Identify the type of claim you are adjusting by checking the appropriate box: BCBSRI, BlueCard, FEP, Workers Compensation, or New England Health Plan (NEHP).
3. Fill in the 'Date' field with the current date of submission.
4. Provide your 'Provider Name' along with the 'Group Name' in the designated fields on the form.
5. Enter your National Provider Identifier (NPI) number in the respective area.
6. List the name of the office contact person and their phone number for any follow-up.
7. Input the member’s name and Member ID as required.
8. Attach supporting documentation as needed. Select the appropriate type of attachment, such as CMS-1500 Claim or UB-04 Claim Form, and ensure compliance with submission guidelines.
9. Specify the reason for the adjustment by checking the applicable box or providing additional details in the designated space.
10. Include any further comments that might assist in reviewing the claim adjustments.
11. Finally, remember to save your changes, and you may download, print, or share the completed form as necessary for submission.

Complete your claim adjustment forms online today for efficient processing!