Claim Appeals/Adjustment Request Form

HEALTH PLAN CLAIM APPEAL/ADJUSTMENT REQUEST FORM

Providers should use this form to communicate corrections needed on previously adjudicated claims or to dispute payment denials 90 days from the date of denial. A copy of this form along with a new claim should be faxed to 517-394-4590. Failure to follow this step could result in the corrected claim denying as a duplicate submission.
Requested By: Provider /Office Name
Contact Person
Ph #
Email Address
example@example.com
Date

MonthDayYear
Date
Member Name*
ID #
Enter HPMS #
Date of Service

MonthDayYear
Date
Billed Amount
Claim Adjustment Reason

Correction to units PriorAuthorization Number AddedCorrection to Charge AmountAddition/Correction of ModifierCorrection to Place of Service Bill TypeCorrection to Procedure (CPT)/Revenue codeCorrection to Primary Diagnosis MDCH Consent AttachedDuplicate Service on same DOSOther (Specify)
Please describe the reason for the appeal or adjustment
Upload supporting documentation

Cancelof
Should be Empty: