Get MVP Health Care Claim Adjustment Request Form 2013-2024

Check the box that best describes the purpose for submitting the Claim Adjustment Request Form and attachments. CLAIM ADJUSTMENT REQUEST FORM Please attach a copy of this completed form when returning claims to MVP Health Care for adjustments. Mvphealthcare. com/provider/morecontactinfo. html. DO NOT USE THIS FORM TO SUBMIT APPEALS FOR No Authorization / Prior Authorization Obtained Before Service Rendered / Medical Necessity / Inpatient Hospital Please submit one claim per adjustment form and do not highlight any fields on this form or any attachments. If you have questions about completing this form please call the Customer Care Center for Provider Services at 1-800-684-9286. Health care providers in MVP s West region Rochester/Buffalo may call 1-800-999-3920. For Appeals mailing addresses go to www. An asterisk denotes required information* Today s Date Document Claim Member ID Date of Service Provider ID Name NPI Tax ID Contact Information Phone Coordination of Benefits Information 1. Alternate Insurance Information/EOB Coverage Attached Requested Documentation Enclosed 1. Surgical or Surgical Modifier 2. Office Notes 3. Surgical/Operative Reports Fax 2. No-Fault/Workers Comp Information/EOB Attached 4. Path/Rad Findings 5. Code Review/Asst. Surg* 6. Follow-up Days 7. Transportation Run Record 8. Manufacturer s Invoice 9. Medical Record Review 3. COB-related Adjustment 10. Evidence of Qualifying Stay 11. Second Level Clinical Review Check Reason for Adjustment Request please check only one Options 1-7 require a corrected UB-04 or CMS-1500 to be attached showing all changes. 1. Added/Deleted Charges 2. Date of Service Correction 3. Diagnosis Correction 4. CPT/Modifier/ICD Procedure Code UB-04 Box 80 Correction 5. Place of Service Correction 6. Quantity Correction 7. Copay/Deductible/Coinsurance Adjustment 8. Timely Filing Issue 9. Duplicate Denial Error 10. Implant/High-Cost Drug 11. Provider Information Correction 12. Referral or Prior Auth Now on File Invoice Attached Please note reason for adjustment or untimely filing or note the rationale for modifier use Please return this completed form and any supporting documentation to MVP Health Care P. If you have questions about completing this form please call the Customer Care Center for Provider Services at 1-800-684-9286. Health care providers in MVP s West region Rochester/Buffalo may call 1-800-999-3920. For Appeals mailing addresses go to www. An asterisk denotes required information* Today s Date Document Claim Member ID Date of Service Provider ID Name NPI Tax ID Contact Information Phone Coordination of Benefits Information 1. Alternate Insurance Information/EOB Coverage Attached Requested Documentation Enclosed 1. Surgical or Surgical Modifier 2. Alternate Insurance Information/EOB Coverage Attached Requested Documentation Enclosed 1. Surgical or Surgical Modifier 2. Office Notes 3. Surgical/Operative Reports Fax 2. No-Fault/Workers Comp Information/EOB Attached 4. .