Get Single Claim Adjustment Request Form - Vt

Filling out the Single Claim Adjustment Request Form - VT is an essential process for users seeking to request adjustments to previously paid claims. This guide provides detailed, step-by-step instructions to ensure accurate completion of the form online.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In the 'Internal Control Number' section, enter the 15-digit Internal Control Number (ICN) found on the remittance advice. If all details for the ICN require adjustment, indicate ‘ALL’.
3. Input the beneficiary name in the designated field, ensuring it matches the name associated with the claim.
4. Enter the Medicaid identification number of the beneficiary in the 'Beneficiary Number' section.
5. In the 'Provider Name, Address & Number' section, enter the required information including the provider's name, address, Medicaid provider number, NPI number, and Taxonomy Code.
6. Fill in the 'From DOS' and 'To DOS' fields with the dates of service for the claim that is being adjusted.
7. Provide the billed amount in the 'Billed Amt.' field and the amount that was paid in the 'Paid Amt.' section.
8. Enter the remittance advice date from which the claim was paid in the 'R/A Date' section.
9. Specify the reason for the adjustment in the 'Please Specify Reason for Adjustment' section, being sure to include any necessary new information related to the adjustment.
10. Ensure that all fields are completed accurately, including your signature and date. The request will be returned if these elements are missing.
11. Once all information is entered, save changes to the document, with options to download, print, or share the form for submission.

Begin the process of filing your Single Claim Adjustment Request Form - VT online now.