Follow the steps to complete your request successfully.

1. Press the ‘Get Form’ button to acquire the Ucare Adjustment Recoupment Request Form and open it in the designated editor.
2. Input today's date in the designated field to indicate when you are submitting the form. This provides a record for both you and Ucare.
3. Complete the ‘Provider Name’ and ‘UCare Provider #’ fields with the relevant details of your practice or organization.
4. Fill in the ‘Member Name’ field with the individual’s name associated with the claim, followed by their ‘NPI Number’ and ‘Member Number’. Ensure all entries are accurate.
5. Provide your correspondence information, including the ‘Phone’, ‘Contact Name’, ‘Address’, ‘City’, ‘State’, and ‘Zip Code’. This allows Ucare to reach you if needed.
6. In the ‘Request Details’ section, enter the ‘Date of Service (DOS)’ and the ‘Claim Number’ associated with your request.
7. Specify the ‘Recoup Amount $’ you are requesting and select any relevant issues from the options such as ‘COB Related’, ‘Payment Dispute’, or ‘Billed In Error’. Include any details that may support your claim.
8. If applicable, indicate if you are submitting medical records by checking the box labeled ‘Medical Records Enclosed’. Also, clarify the situation with the options available such as ‘Duplicate Payment’ or ‘Wrong Provider Paid’.
9. Once all fields are completed, review your entries to ensure accuracy. Adjust any mistakes before proceeding.
10. Save your form and consider downloading or printing it for your records. Be sure to send the completed form to the designated address or fax number provided in the instructions.

Complete your Ucare Adjustment Recoupment Request Form online today to ensure your recoupment request is processed efficiently.