Get Nm Adjustment/void Request 2007

Filling out the NM Adjustment/Void Request form is a crucial step in managing your claims with the New Mexico Medicaid Program. This guide will help you navigate the online version of the form, ensuring that you correctly complete each section while avoiding common pitfalls.

Follow the steps to successfully complete your request.

1. Click 'Get Form' button to access the NM Adjustment/Void Request form and open it in your web-based editor.
2. Identify whether you require an adjustment or a void by checking the appropriate box. An adjustment is for changing information on a paid claim, while a void requests the complete recoupment of a payment.
3. Provide your provider information by entering either your NPI or NM Medicaid billing provider number. Be sure to check the box that corresponds to the number you are using. Additionally, fill in your facility name, phone number, and mailing address.
4. In the history information section, input the necessary claims details exactly as they appear on your NM Medicaid Remittance Advice. This includes your TCN, which is limited to 17 digits.
5. For the adjustment or void reason, include a brief explanation of why you are making this request, such as 'Billed incorrect units.'
6. Indicate any specific boxes or lines on the claim forms that need changes by listing the box number(s) and line number(s). For example, 'Change units in Box 24G, line 2.'
7. If applicable, indicate whether you have been overpaid by checking one of the options available.
8. Sign the form in the authorizing signature section and provide the date in the designated field.
9. Leave the ACS use only section blank, as it is for ACS processing purposes.
10. After completing the form, ensure that you save your changes. You can download, print, or share the document as needed.

Complete your NM Adjustment/Void Request online now for efficient claim management.