Adjustment Request Form

Adjustment requests can now be submitted electronically from our web site, rather than being mailed in. Simply complete the requested fields and add attachments, as necessary. If you have any questions, please call Provider Services at 800-963-1001.

To request an adjustment, the following items must be submitted for each individual claim:

• A completed Adjustment Request Form
• Claim number
• Remittance Advice, Explanation of Benefits, or Coordination of Benefits documentation (as applicable)?
  • Adjustment requests with claims attached will be returned to the sender.