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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

Claim Check 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:

Attach Files

File Remove File

Section 3: Office Contact Information

Requested By

Phone

Requesters Email

- required