Indiana Application for Adjustment of Claim for Provider Fee - SF 18487

• Category: Indiana Workers Compensation - Official - General
• State: Indiana
• Control #: IN-18487-WC
• Format: PDF

Description

Application for Adjustment of Claim for Provider Fee - SF 18487 Indiana Application for Adjustment of Claim for Provider Fee — SF 18487 is a form completed by a healthcare provider in Indiana to request an adjustment of a provider fee. The form is used to request adjustments to the fee schedule on the basis of a change in circumstances, such as a change in the medical record or the receipt of additional information. The form includes sections for the provider to provide information about the patient and the services provided, as well as a section for the provider to explain the circumstances that necessitate the adjustment of the fee. The provider must also attach any supporting documentation to the form to assist with the adjustment request. There are two types of Indiana Application for Adjustment of Claim for Provider Fee — SF 18487 forms: one for inpatient services and one for outpatient services.

Indiana Application for Adjustment of Claim for Provider Fee — SF 18487 is a form completed by a healthcare provider in Indiana to request an adjustment of a provider fee. The form is used to request adjustments to the fee schedule on the basis of a change in circumstances, such as a change in the medical record or the receipt of additional information. The form includes sections for the provider to provide information about the patient and the services provided, as well as a section for the provider to explain the circumstances that necessitate the adjustment of the fee. The provider must also attach any supporting documentation to the form to assist with the adjustment request. There are two types of Indiana Application for Adjustment of Claim for Provider Fee — SF 18487 forms: one for inpatient services and one for outpatient services.