Adjustment Request Form – Medicaid

Please complete the electronic form below to submit a claim adjustment request. The following items must be submitted for each individual claim:
- 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.
If you have any questions, please call Neighborhood Provider Services at 800-963-1001.
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Accepted file types: pdf, Max. file size: 10 MB.
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1. Please complete the following:
You are submitting an Adjustment Request for ACCESS (Rite Care) / TRUST (Rhody Health Partners). To choose Integrity, click here.
Is 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.
- No
Member ID #*
Member Name*
First Last
Claim number*
Beginning Date of service*
MM slash DD slash YYYY
Ending Date of service*
MM slash DD slash YYYY
Provider Name*
NPI#*

10 digits
Provider Address*
Street Address Address Line 2 City State ZIP Code
Contact Name*
Contact Phone*
Contact Email*
2. Adjustment reason
Select an Adjustment reason*
- Claim Processed Incorrectly
- NOPCP Denial
- Coordination of Benefits
- Retraction of Payment (indicate which claims)
- Duplicate Claim
- Timely Filing Limit
- Other:
Specify Other Adjustment Reason*
3. Description of request:
*
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If you have any questions, please contact Provider Services at 800-963-1001. Thank you.

1. Please complete the following:

2. Adjustment reason

3. Description of request: