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Get MVP Health Care Claim Adjustment Request Form 2010

CLAIM ADJUSTMENT REQUEST FORM Please attach a copy of this completed form when returning claims to MVP Health Care for adjustments. Check the box that best describes the purpose for submitting the Claim Adjustment Request Form and attachments. If you have questions on completing this form please call Provider Claims Services at 800 684-9286. West Region Rochester and Buffalo should call Provider Services at 585 325-3114 or 800 999-3920 THIS FORM IS NOT REQUIRED FOR THE FOLLOWING APPEALS No Authorization / Pre-Certification obtained PRIOR to service Medical Necessity Inpatient Hospital Mailing addresses for Appeals are at www. mvphealthcare. com on the Contacting MVP resource Today s Date Please submit one claim per adjustment form and do not highlight any fields on this form or any attachments. An asterisk denotes required information* Document claim Member ID Date of Service Provider Name Member Name Contact Name Provider ID Tax ID Contact Phone Coordination of Benefits Information Contact Fax 1. Alternate Insurance Information/EOB Coverage Attached 2. No-Fault /Workers Comp Information/EOB Attached 3. COB Related Adjustment 7. Transportation Run Record Requested Documentation Enclosed 1. Surgical or Surgical Modifier 4. Path/Rad Findings 8. Manufacturer s Invoice 2. Office Notes 5. Code Review/Asst. Surg* 9. Medical Record Review 3. Surgical/Operative Reports 6. Follow-up Days 10. Evidence of Qualifying Stay 11. Second Level Clinical Review Check Reason for Adjustment Request please check only one Options 1-8 require a corrected UB-92 or CMS-1500 to be attached showing all charges 1. Added/Deleted Charges 8. Copay/Deductible/Coinsurance Adjustment 9. Timely Filing Issue 3. Diagnosis Correction 10. Duplicate Denial Error 4. CPT/Modifier Correction 11. Implant/High Cost Drug Invoice Attached 5. ICD-9 Procedure UB92-Box 80 Correction 12. Provider Information Correction 6. Place of Service Correction 13. Referral or Pre-Auth Now on file- 7. Quantity Correction Please note reason for adjustment untimely filing or rationale for modifier use Please return this completed form and any supporting documentation to MVP Health Care P. Check the box that best describes the purpose for submitting the Claim Adjustment Request Form and attachments. If you have questions on completing this form please call Provider Claims Services at 800 684-9286. If you have questions on completing this form please call Provider Claims Services at 800 684-9286. West Region Rochester and Buffalo should call Provider Services at 585 325-3114 or 800 999-3920 THIS FORM IS NOT REQUIRED FOR THE FOLLOWING APPEALS No Authorization / Pre-Certification obtained PRIOR to service Medical Necessity Inpatient Hospital Mailing addresses for Appeals are at www. West Region Rochester and Buffalo should call Provider Services at 585 325-3114 or 800 999-3920 THIS FORM IS NOT REQUIRED FOR THE FOLLOWING APPEALS No Authorization / Pre-Certification obtained PRIOR to service Medical Necessity Inpatient Hospital Mailing addresses for Appeals are at www. mvphealthcare. com on the Contacting MVP resource Today s Date Please submit one claim per adjustment form and do not highlight any fields on this form or any attachments. .

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