Adjustment-Correction Request {BI-411} | Pdf Fpdf Doc Docx | West Virginia

Adjustment-Correction Request {BI-411}

West Virginia/Workers Comp/
Adjustment-Correction Request {BI-411} | Pdf Fpdf Doc Docx | West Virginia

Adjustment-Correction Request Form

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This is a West Virginia form that can be used for Workers Comp.

Last updated: 8/9/2006
BI-411 01/06 Adjustment / Correction Request INSTRUCTIONS FOR COMPLETION APPEAR ON REVERSE SIDE. 1. Transaction Control Number: (17 digits) 2. Provider Number: (FEIN plus 2-digit location number) 4. Claimant's Name: (Last, First and Middle) 3. Claimant's Social Security Number: 5. Claim Number Return completed form to: BrickStreet Insurance P. O. Box 3151 Charleston, WV 25332-3151 6. Date of Injury: ITEMS 8, 9 AND 10 FOR BRICKSTREET INSURANCE USE ONLY. 8. Credit Number: 9. Returned Warrant Number: 10. Approved By: 11. Correction ­ Complete only those items listed incorrectly or omitted on the remittance advice Item As Listed on Remittance Advice (a) Claim Number (b) Claimant Social Security Number (c) Date of Injury (d) Date(s) of Service (e) Procedure / Drug Code (f) Units of Service (g) Line Item Charge (h) Revenue Code / Rate (i) Tooth Number (j) Provider Name (k) Provider Number (FEIN plus 2-digit location number) (l) Third Party Payment (m) Other (list) 12. Narrative Description for Adjustment / Correction Request: Corrected Information 13. As provided by statute, this is to certify that the medication(s) or services were provided or rendered as outlined above and that no other or additional charge for such medication(s), treatment, appliance or device has been or will be made against any person, firm or corporation. Signature: Date: 15. Provider Name, Address and Telephone Number: BrickStreet Mutual Insurance P.O. Box 3151 Charleston, WV 25332-3151 American LegalNet, Inc. www.USCourtForms.com USE OF THE ADJUSTMENT / CORRECTION REQUEST FORM The Adjustment / Correction Request form should be used to correct information listed incorrectly on the Remittance Advice which resulted in an over- or underpayment OR a denial. This form should NOT be used when the payment or denial was the result of Fund policy regarding the services provided. Only one line item may be corrected on each Adjustment / Correction Request form unless you attach a copy of the original invoice, highlighting each line to be corrected or adjusted. INSTRUCTIONS FOR COMPLETION OR ADJUSTMENT / CORRECTION REQUEST FORM Item 1, "Transaction Control Number": Enter the 17-digit Transaction Control Number (TCN) assigned to the bill you wish to correct or adjust. This number is found on the Remittance Advice on which the bill was either denied or mispaid. Item 2, "Provider Number": Enter the business Federal Tax Number as it is reported to the Internal Revenue Service, plus the two-digit location number assigned by the Fund. This number serves as your provider number. Item 3, "Claimant's Social Security Number": Enter the claimant's nine-digit Social Security Number. Item 4, "Claimant's Name": Enter the claimant's full name ­ last, first and middle. Item 5, "Claim Number": Enter the claim number assigned to the claimant's approved occupational injury or exposure report. Item 6, "Date of Injury": Enter the official date of injury or date of last exposure for the compensable condition for which you supplied services. Item 7, "Reason for Adjustment or Correction": Please explain for what reason you are requesting an adjustment or correction by using one of the codes listed below: Adjustment / Correction Reason Codes C = Third Party Recovery: If you collected money from a payer (such as Federal Black Lung benefits) AFTER the Fund made its payment. D = Bill Error: If either the provider or the Fund made a clerical error which resulted in a mispayment or invoice denial. E = Change in Compensability Status: If the bill was denied because the claim was not ruled compensable until a later date. Items 8, 9 and 10: These fields are for internal use ONLY. Please leave blank. Item 11, "Correction(s)": Enter a correction to any field listed which resulted in a denial or mispayment. List the item as it was reported on the Remittance Advice, then list the corrected version in the column directly to the right of the incorrect version. If the item was omitted from the Remittance Advice, leave the left-hand column blank. Leave blank any field which was reported correctly. Item 12, "Narrative": Please explain as briefly as possible the reason you are requesting an adjustment or correction. If absolutely necessary, attach a letter of explanation or copy of the original bill. Items 13 and 14, "Signature" and "Date": The provider himself or a legally responsible designee must sign and date the form. Signature stamps are acceptable. Item 15, "Provider Name, Address and Telephone Number": Enter your business name and address, with telephone number. Submit your Adjustment / Correction Request form to the same address as you would original bills. (See front of form for address.) American LegalNet, Inc. www.USCourtForms.com