Get Adjustment Form - De Medical Assistance Program

The Adjustment Form for the Delaware Medical Assistance Program is designed to help users request necessary adjustments to their claims. This guide will provide you with step-by-step instructions to ensure that you accurately complete the form online, facilitating a smooth adjustment process.

Follow the steps to fill out the form correctly and efficiently.

1. Click ‘Get Form’ button to obtain the Adjustment Form and open it in your preferred document editor.
2. Enter your provider Medicaid number in the designated field. This is your unique 10-digit provider number found on the upper left corner of your remittance advice (RA).
3. In the next field, input your taxonomy number, which is located in the upper left corner of your RA.
4. Next, fill in the provider name. This information can be found in the lower right corner of the first page of your RA.
5. Enter your mailing address in the provided section, also found in the lower right corner of your RA.
6. Input the Claim ICN, a unique 15-digit claim identification number present on the Paid Claim page of your RA.
7. Enter the client Medicaid number, a 10-digit identifier found on the Paid Claim page of your RA following the client’s name.
8. Fill in the client's name exactly as it appears on the RA, located on the Paid Claim page.
9. Enter the RA number that can be found in the upper right corner of your RA.
10. Input the RA date from the top of your RA.
11. Clearly state the correct billing information. If you need to correct a specific claim line, include the line number along with the incorrect and correct information.
12. Select the appropriate requested action by checking the relevant box.
13. The form must be signed and dated by the person completing it.
14. If applicable, input the Medicare allowable amounts and payment information in the correct fields.
15. After completing all sections, make sure to review your information for accuracy. You can then save any changes before downloading, printing, or sharing the completed form.

Start filling out your Adjustment Form online today to ensure timely processing of your request.