Washington > Workers Comp > Crime Victims Compensation
Providers Request For Adjustment F800-064-000 - Washington
| Providers Request For Adjustment Form. This is a Washington form and can be used in Crime Victims Compensation Workers Comp . |
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NO STAPLES IN BAR CODE AREA Dept of Labor and Industries Crime Victims Compensation Program PO Box 44520 Olympia WA 98504-4520 CHECK ONE PROVIDER'S REQUEST FOR ADJUSTMENT DO NOT WRITE IN SPACE NO PAYMENT - DO NOT USE THIS FORM. (SEE REVERSE SIDE FOR INSTRUCTION.) TOTAL /PARTIAL OVERPAYMENT PARTIAL UNDERPAYMENT INSTRUCTIONS APPEAR ON REVERSE SIDE 1) Claimant's name 3) Provider name 5) L&I provider number / NPI Last First M. Initial 2) Claim number on remittance advice Please type or print in dark ink 4) ICN number on remittance advice (17-digit number) SUBMIT ONLY ONE FORM FOR EACH ICN ENTER ONLY THE INFORMATION YOU WANT CHANGED 6 Line Item No a) From/to Date of Service or Covered Dates b) P O S c) T O S d) Procedure Code/ Revenue Code/NDC e) Code Mod f) ICD-9-CM Diagnosis/ Side of body g) Tooth No h) Charge j) i) Days/ Days Units/ supply Qty k) Description REASON FOR ADJUSTMENT: Write the reason for your request. Example: 2 units were billed in error; should have billed 4 units. Insurance wasn't considered (attach EOB). Attach required reports and/or other documentation necessary to support your request. A copy of the original bill is also helpful. Date Phone number ( ) Signature F800-064-000 provider's request for adjustment 08-09 American LegalNet, Inc. www.FormsWorkFlow.com ADJUSTMENT REQUEST FORM IF YOUR ORIGINAL BILL WAS DENIED IN FULL, DO NOT USE THIS FORM. PLEASE SUBMIT A NEW BILL. THE ADJUSTMENT REQUEST FORM MAY BE USED IN THE FOLLOWING INSTANCES: TOTAL OVERPAYMENT ----- Entire bill was paid in error. You may either submit an Adjustment Request Form and we will process a credit to recover the money from your future payment(s); OR you may issue a refund check directly to the Department. If a refund is submitted, you must attach a copy of the remittance advice indicating the Internal Control Number (ICN) overpaid. Submit refunds to: Cashiers Office Department of Labor and Industries (L&I) PO Box 44835 Olympia WA 98504-4835 PARTIAL OVERPAYMENT --- A portion of the bill was overpaid. Complete Adjustment Request Form with correct information for the procedures/items paid incorrectly. UNDERPAYMENT --------------- A portion of the bill was underpaid. Complete adjustment request form with correct information for the procedures/items paid incorrectly. Corrections or justification and/or reports must be included. INSTRUCTIONS FOR COMPLETING ADJUSTMENT REQUEST 1. CLAIMANT'S NAME: Clearly print claimant's full name. 2. CLAIM NUMBER ON REMITTANCE ADVICE: Enter the 7-digit number found in the Claim Number column on the remittance advice. 3. PROVIDER NAME: Enter the name of the provider who performed these services. 4. ICN NUMBER: Enter the 17-digit number found in the ICN column on the remittance advice, to identify the ICN needing correction. 5. L&I PROVIDER NUMBER / NPI: Enter the L&I provider account number or NPI. 6. SERVICE ITEMIZATION: Enter the line item number(s) that corresponds to the line item number on your original bill. Enter ONLY the information you want to correct, as it should have appeared on your original bill. Example: 2 units of service billed on line 3 and should have billed 4 units. Enter line item number 3 in column 6 and 4 in column i. If insurance wasn't considered, attach EOB and explain in "Reason for Adjustment" that insurance has paid. a. From/to Date of Service or Covered Dates: Date of service, from and to date if date span previously billed. Admit and discharge date for hospital bill. b. Place of Service: (POS) Two digit code identifying the place service was performed. c. Type of Service: (TOS) One digit code identifying the type of service performed. d. Procedure Code/Revenue Code/NDC: Identify correct procedure, hospital service or national drug code. e. Code Mod: Modifier used to identify special circumstances for a service or procedure. f. ICD-9-CM Diagnosis/Side of Body: ICD-9-CM diagnosis code for condition treated. Designate left or right side of body where applicable. g. Tooth Number: For dental services only. Enter the two digit identification number of the specific tooth number treated (e.g., 08). h. Charge: Total of charges for services provided this line. i. Days/Units/Quantity: Total days stay for hospital accommodation codes, unit of service for procedure (time units, hours, miles, etc.), number of items (tablets, milliliters, etc.). j. Days Supply: Total number of days a prescription is intended to cover. k. Description: Describe procedure or service. If you have questions completing this form, please call 1-800-762-3716. F800-064-000 provider's request for adjustment - backer 08-09 American LegalNet, Inc. www.FormsWorkFlow.com
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