Get Claim Adjustment Form - Intotal Health

Filling out the Claim Adjustment Form - INTotal Health is essential for ensuring accurate processing of your claims. This guide provides a clear and supportive walkthrough to help you complete the form online efficiently.

Follow the steps to successfully complete the Claim Adjustment 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. Ensure that the name matches your official credentials.
3. Next, enter your Provider NPI number. This is a unique identifier that must be accurately provided.
4. Fill in the insured’s Medicaid ID number, ensuring that it corresponds with the patient's information.
5. Indicate the date when the claim was originally filed, selecting either CMS 1500 or UB 04 format as applicable.
6. Complete the patient’s name and the account number assigned to the case.
7. Specify the referring provider's name and attach any relevant referral or authorization number.
8. List the dates of service, providing comprehensive information regarding when the treatment or service was rendered.
9. Provide the provider name and address where treatment was conducted, including the claim number and charge amount.
10. Select the place of treatment from the given options: Office, Inpatient Hospital, Emergency Room, or Other.
11. In the reason for request section, check the applicable box for your request type, such as adjustment or reconsideration. Be sure to include any required medical records.
12. In the final field, describe the problem in detail and outline the requested action. Clarity here is crucial for the review process.
13. Once you have completed filling out all sections, review your entries for accuracy. You can then save your changes, download, print, or share the completed form as needed.

Take the first step towards effective claim adjustments by completing the Claim Adjustment Form online today.