Get Payment Adjustment Request Form - Utah Medicaid - Utah.gov

Completing the Payment Adjustment Request Form for Utah Medicaid online can streamline your submission process and help ensure that your adjustments are processed efficiently. This guide will walkthrough each section to assist you in accurately filling out the form.

Follow the steps to fill out the Payment Adjustment Request Form online

1. Click ‘Get Form’ button to initiate the process and access the electronic form. This will allow you to complete it directly on your device.
2. Confirm that you have selected the correct form, which is the Payment Adjustment Request Form. Read any accompanying instructions carefully to familiarize yourself with the requirements.
3. Begin filling out the required fields. For claims that are over three years old, select the appropriate payment adjustment type by checking the relevant box on the form, either for Credit Balance or All other Payment Adjustments.
4. If you are filling out the Credit Balance adjustment, complete only the designated red boxes: 1-9, and 30 & 31. Remember to attach a copy of the Credit Balance letter, if available.
5. For all other Payment Adjustments, complete both the red and blue areas from boxes 2-31. Make sure to include an Explanation of Benefit (EOB) for Third Party Liability adjustments in boxes 17-19.
6. Fill in all relevant provider and patient information in the specified boxes, including provider name, address, tax ID, member name, and claim number.
7. Provide detailed information for the adjustment, including the reason for the adjustment, dates of service, procedure code, and any changes in charges.
8. Once you have completed all necessary fields, review your entries to ensure all information is correct and legible. Incomplete or incorrect forms may be returned for corrections.
9. You can now save the completed form, print it, or share it as required. Ensure that you follow any additional steps for mailing the form and payment to the appropriate addresses listed.

Start your online process for completing the Payment Adjustment Request Form today.