F245-183-000 Provider222s Request for Adjustment 10-2017 Mail completed form to: Department of Labor and Industries PO Box 44269 Olympia WA 98504-4269 Provider222s Request for Adjustment Submit one form for each ICN. Enter the information you want changed. Attach required reports and/or other documentation necessary to support your request. If your bill was denied in full, don222t use this form. Submit a new bill. Send corrected information to the address above. Send refunds only to the address on the next page. See complete instructions on the next page. Reason for adjustment: Total/partial overpayment Partial underpayment Bill information: Worker222 name (last name, first name) Claim number L&I provider number or NPI Provider name ICN on remittance advice (17-digit number) Information to be changed: Line item no. To/from date of service or covered dates POS TOS Procedure code/revenue code/NDC Code mod ICD code Tooth no. Charge Days/units/qty Days supply Description Reason for adjustment: Example: 2 units were billed in error; should have billed 6 units. Signature: Print name Signature Phone number Date American LegalNet, Inc. www.FormsWorkFlow.com F245-183-000 Provider222s Request for Adjustment 10-2017 Instructions for completing the Provider222s Request for Adjustment Reason for Adjustment Select reason for submitted adjustment. Total/partial overpayment A total overpayment is when the entire bill was paid in error. A partial overpayment is when a portion of the bill was overpaid. You have two options to return the money to the department. 1. Complete and submit this form and the department will deduct the overpayment from your future payments. Mail the form to the address on the previous page. 2. You may repay the money to the department. Send your check with the a copy of the remittance advice to: Department of Labor and Industries Cashiers Office 226 MIPS Deposit PO Box 44835 Olympia WA 98504-4835 Underpayment Complete an Adjustment Request for each ICN that you think was underpaid with the correct information for the procedures/items. Attach any required reports and/or other documentation to support your request. Bill information: Worker222s name Enter the worker222s name in the last name, first name, middle initial format. Claim number Enter the claim number for the worker. The claim number can be found in the Claim Number column of the remittance advice. Provider222s name Enter the name of the provider who performed the services. L&I provider number or NPI Enter the L&I provider number or NPI for the provider who performed the services. ICN Enter the 17-digit number found in the ICN column of the remittance advice for the procedure/item you are adjusting. Information to be changed: Line item no. Enter the line item number(s) from your original bill that you want to correct. To/from date of service or covered dates Date of service, to and from date if date span, or admit and discharge date for hospital bills. POS Two-digit code identifying the place of service. TOS One-digit code identifying the type of service performed. Procedure code/revenue code/NDC Enter the correct procedure, hospital service, or national drug code. Code mod Enter the correct modifier used to identify special circumstances for a procedure or service. ICD code Enter the ICD code for condition treated. Enter side of body if applicable. Tooth no. For dental services only. Enter the two-digit code identification number for the specific tooth number treated. Charge Total charge for services provided for this line only. Days/units/quantity Total days stayed for hospital accommodation codes, units of service for procedure (time units, miles, etc), or number of items (tablets, milliliters, etc). Days supply For pharmacy services only. Total number of days a prescription is intended to cover. Description Description of the procedure or services provided. American LegalNet, Inc. www.FormsWorkFlow.com