PROVIDER CLAIM ADJUSTMENT REQUEST FORM Use this form as part of Sunshine Health's Provider Claims Inquiry process to request adjustment of claim payment received that does not correspond with payment expected.
be filed within 45 calendar days of original decision shown on your EOP. For more information, see Sunshine. Health's Provider Manual. (This form may be ...
Sunshine Health Claim Adjustment Form | Finding reliable health information
PROVIDER CLAIM ADJUSTMENT REQUEST FORM Use this form as part of Sunshine Health's Provider Claims Inquiry process to request adjustment of claim payment received that does not correspond with payment expected. NOTE: Adjustment Requests must be submitted within 90 calendar days of the original determination or Explanation of Payment (EOP) for reconsideration. All fields in the box immediately below are required information Provider Name Provider Tax ID# Control Number Date(s) of Service Member Name Member (RID) Number Reason for Adjustment Request (please check): Claim was denied for no authorization, but authorization # ___________ was obtained. Claim was denied for no authorization, but no authorization is required for this service. Claim was denied for untimely filing in error (proof of timely filing should be attached). Claim was paid to wrong provider Claim was paid for incorrect amount Other (please explain below): __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Date of Request_____________ Name of Requestor__________________________________________ Requestor Phone Number ____________________ NOTE: If original claim submitted requires a correction, such as a valid procedure code, location code or modifier, include a copy of that page from your EOP with the claim circled, along with a copy of the new, corrected CMS-1500 or UB-04 form, marked "Corrected Claim" across the top. Mail completed form(s) and attachments to: Sunshine Health Post Office Box 3070 Farmington, MO 63640-3823 Attach a copy of the EOP(s) with Claim(s) to be adjudicated clearly circled with the response to your original request for reconsideration. Important Notice: Sunshine Health Claims Office will make reasonable efforts to resolve this request within 30 calendar days of receipt. That resolution may be: 1. Reprocessing your claim and issuing a notice to you on a current EOP and payment, or 2. A determination that reprocessing is not appropriate and issuing you a letter to that effect. This Adjustment Request form does not initiate an Informal Claim Dispute / Objection and does not push back the deadline to file a written Informal Dispute / Objection, which is Step 1 of an official appeal and must be filed within 45 calendar days of original decision shown on your EOP. For more information, see Sunshine Health's Provider Manual. (This form may be photocopied)Sunshine Health Adobe PDF Library 15.0