Department of Labor and Industries Crime Victims Compensation Program PO Box 44520 Olympia WA 98504-4520 Provider's 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, don't use this form. Submit a new bill. See complete instructions on the next page. Partial underpayment Claim number L&I provider number or NPI Reason for adjustment: Total/partial overpayment Bill information: Provider's name ICN on remittance advice (17-digit number) Claimant's name (last name, first name) Information to be changed: Line item no. To/from date of service or covered dates P O S T O S 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 F800-064-000 Provider's Request for Adjustment 12-2013 American LegalNet, Inc. www.FormsWorkFlow.com Instructions for completing the Provider's 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. 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 ­ MIPS Deposit PO Box 44835 Olympia WA 98504-4835 2. 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. Enter the claimant's name in the last name, first name, middle initial format. Enter the claim number for the claimant. The claim number can be found in the Claim Number column of the remittance advice. Enter the name of the provider who performed the services. Enter the L&I provider number or NPI for the provider who performed the services. Enter the 17-digit number found in the ICN column of the remittance advice for the procedure/item you are adjusting. Enter the line item number(s) from your original bill that you want to correct. Date of service, to and from date if date span, or admit and discharge date for hospital bills. Two-digit code identifying the place of service. One-digit code identifying the type of service performed. Enter the correct procedure, hospital service, or national drug code. Enter the correct modifier used to identify special circumstances for a procedure or service. Enter the ICD code for condition treated. Enter side of body if applicable. For dental services only. Enter the two-digit code identification number for the specific tooth number treated. Total charge for services provided for this line only. Total days stayed for hospital accommodation codes, units of service for procedure (time units, miles, etc), or number of items (tablets, milliliters, etc). For pharmacy services only. Total number of days a prescription is intended to cover. Description of the procedure or services provided. American LegalNet, Inc. www.FormsWorkFlow.com Bill information: Claimant's name Claim number Provider's name L&I provider number or NPI ICN 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/quantity Days supply Description F800-064-000 Provider's Request for Adjustment 12-2013