HealthPlus Claims Adjustment Form

Instructions

  1. Please complete all information in Section 1

  2. Please indicate which type of adjustment is needed, in Section 2

  3. Please complete Section 3 with all contact information for question.
    DENIALS MUST BE REBILLED. USE THIS FORM FOR INCORRECT PAYMENTS ONLY.

Section 1: General Information
Enter your HealthPlus Provider # :
Provider Name :
Member Name : Member ID #:
Claim # that needs to be adjusted :
Date of Service: (list all that apply):
Billed Charges: (for each line item):

 

Section 2: Type of Claim Information

Appeals

Benefit Appeal
ClaimCheck appeal (documentation required)
Fax to (810) 230-2106

Coding
(a corrected claim must be submitted for billing corrections)

Correction to units (count)
Correction to diagnosis code
Correction to procedure/revenue code
Correction to location code
Correction to modifier
Correction to date of service
Correction to anesthesia time
Missing or change in DRG
Supporting Comments:

Member

Processed under incorrect member

Payment Amount

Duplicate payment. Original payment on EOP dated:

Correction to charge amount
Overpayment - Explain the reasoning.

Service is not a duplicate - Explain the reasoning.

COB overpayment due to two payers- Explain

Provider
Processed under incorrect provider/provider tax identification number. Should be:

Other Provider:

Other comments:

 

Section 3: Office Contact Information

Requested By :
Phone :
Requesters Email :