Fillable Adjustment Appeal Request Form

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Adjustment Appeal Request Form

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The Adjustment Appeal Request Form form is 1 page long and contains:

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18 other fields

Country of origin: OTHERS
File type: PDF

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ProviderClaimReconsiderationRequestForm*



AdjustmentRequestRecoupmentRequestAppealRequestSecondaryAppealRequest



Adjustment/Recoup Request:  To be completed only when requesting an adjustment in situations where the original claim processed incorrectly

eventhoughcorrectclaiminformationwasprovided.

AppealRequest:Tobecompleted whenrequestingreconsiderationof apreviously adjudicated  claim,but there isno additionalclaim datato be

submitted.Secondlevelappealsmustbesubmittedwithadditionalinformationoverandabovewhatwassubmittedwiththeinitialappeal.



*BillingProviderInformationUCareContractedProvider? YesNo

ProviderName: UCareProvider#:

NPINumber: UMPINumber

(ifapplicable):

*ClaimInformation

MemberName:UCareMemberNumber:  

Date(s)ofService:

ClaimNumber(s):



*ReasonforRequest(seedefinitionsonreverseside)

PaymentDisputeTimelyEligibilityMedicalPolicyReviewCodeReviewBilledinError

OtherAuthorization(checkappropriateboxbelow)

NursingHome ElderlyWaiver/PCA InjectableDrug

BehavioralHealth Homecare Other

OutpatientTherapy DMEProcedures



Detaileddescriptionforrequest:

 

*SupportingDocumentationAttached(seeexamplesonreverseside)

RemittanceAdviceMedicalRecordsRefund(onlyiftheclaimsOther

 datehasexceeded12months)

*ContactInformation:

Requester: Phone#:

Total#ofpages: Fax#:

Date:

Pleasefaxormailto: Questions?

UCare–Attn:CLAIMSPleasecallourProviderAssistanceCenter

P.O.Box405612‐676‐3300ortollfreeat1‐888‐531‐1493

Minneapolis,MN55440‐0405

Fax:612‐884‐2186

*Incompleteformswillbereturnedtoproviderwithoutfurtherconsideration.Pleasecompleteallsectionscontaining

anasterisk(*). 

11-3-17



Pleaseusethefollowinggridbelowto determineifyouarerequestinganAdjustment,

RecoupmentorAppeal.

REASONFOR

REQUEST

DESCRIPTION ADJUSTMENTTYPE

SUPPORTING

DOCUMENTATION

PaymentDispute



ProviderDisagreesWith

OriginalClaimPayment

DueToAnIncorrectly

ProcessedClaim.

Adjustment/Recoup

Request



CopyOfFeeScheduleOr

ProviderAgreement

Authorization

DeniedPreviouslyForNo

Authorization.



Appeal



MedicalRecordsAnd

RationaleForService

Performed



AuthorizationOnFile

AuthorizationNowOn

File,ClaimRequires

Reprocessing.

AdjustmentRequest



AuthorizationNumber

TimelyFiling

ClaimSubmittedAfter

FilingDeadline

Appeal

DocumentationSupporting

SubmissionOfAClaim

WithinTheTimelyFiling

Limits

Eligibility

MemberNotEligibleAt

TimeOfService.

Appeal

DocumentationSupporting

Effective/TermDate

MedicalPolicy

Review

RequestToChangeA

UtilizationReview

Decision,OrAnInitial

ClaimDecisionBasedOn

MedicalNecessityOr

Experimental/

InvestigationalCoverage

Criteria.

Appeal



MedicalRecordsAnd

RationaleForService

Performed

CodeReview

ProviderDisagreesWith

OriginalClaimPayment

DueToCoding

Methodology

(I.E.Bundling,Frequency,

Global,Unlisted,PlaceOf

Service,Etc.).

Appeal



RationaleForQuestioning

Payment

BilledInError ClaimBilledInError RecoupRequest N/A

Incompleteformswillbereturnedtoproviderwithoutfurtherconsideration.Pleasecompleteallsectionscontaininganasterisk(*).

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Adjustment Appeal Request Form

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Completed 20 May 2021

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