Adjustment Request Form Add Attachments** Note: Adjustment requests with claims attached will be returned to the sender. ** Upload only PDFAccepted file types: pdf, Max. file size: 10 MB.1. Please complete the following:Which Line of Business are you submitting an Adjustment Request Form for?*Which Line of Business are you submitting an Adjustment Request Form for? *MedicaidIntegrityCommericalIs this adjustment request for services that denied for EVV?*Is this adjustment request for services that denied for EVV? *Yes Note: Only providers rendering home care services should select “yes,” if applicable.NoMember ID #*Medicaid Claim Number*Medicaid Member ID #*Integrity Claim Number*Integrity Member ID #*Commercial Claim Number*Commercial Member Name* First Last Beginning Date of service* MM slash DD slash YYYY Ending Date of service* MM slash DD slash YYYY Provider Name* NPI#* 10 digitsProvider Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact Name* Contact Phone*Contact Email* 2. Adjustment reasonSelect an Adjustment reason* Select All Claim Processed Incorrectly NOPCP Denial Retraction of Payment (indicate which claim) Duplicate Claim Timely Filing Limit Other: Specify Other Adjustment Reason*3. Description of request:*CAPTCHAIf you have any questions, please contact Provider Services at 800-963-1001. Thank you.