How To File an Adjustment Request on a Paper Claim

Requirements for Filing an Adjustment

An adjustment request is processed as a replacement to the original, incorrectly paid claim. The original payment for the claim is completely deducted. All claim items on the request must be correctly completed. An adjustment must be for the entire amount, not just for remaining unpaid amounts or units.

A legible photocopy of the original claim or an entirely new claim can be used when submitting an adjustment.
The provider does not need to send an adjustment request for each claim line that paid incorrectly. All errors can be corrected with one adjustment request.

Adjustments must be received by the Medicaid fiscal agent within one year of the date of payment.

Partially Incorrect Claim Lines on a Claim Form

Use the following procedures when some claim lines on a claim form paid correctly and other lines did not pay correctly.

If some claim lines paid correctly and some lines denied, do not request an adjustment. Cross out the claim lines that were paid, change the total amount billed, correct the errors on the lines that denied, and resubmit the claim. If all the claim lines paid, but some paid incorrectly, request an adjustment.

Make needed corrections and circle the items to be corrected in black ink. Do not cross out the lines that paid correctly. Crossed-out lines are treated as voids and payment for these lines will be recouped.
If one claim line needs to be deleted from a claim that has other lines that paid correctly, request an adjustment not a void. If the request is marked as a void, all the claim lines will be recouped. To delete one line, mark the request an adjustment, circle the line to be deleted, and write “delete” to the side of the line.
You must use black ink.

Adjustment Instructions

When requesting an adjustment or void, the provider must:
·  Resubmit a photocopy of the original claim or a new claim form;
·  Enter the items listed below;
·  Ensure that the items on the adjusted claim match the items on the original
claim, except for the corrections that are made and circled in black ink;
·  Initial and date the form if it is a photocopy, or sign and date it if it is a new
·  Attach copies of the documents that were required for the original claim to
the adjustment request; and
·  Mail the adjustment or void request to the fiscal agent for processing to:

Adjustments and Voids
P.O. Box 7080
Tallahassee, Florida 32314-7080

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