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Includes fields for unit increases/decreases, modifier and telemedicine/covid changes, provider and subscriber identifiers, and home medical equipment return details. 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Please be sure to read theform instructions.  \nRendering Provider NPI \\#   Provider Name   Subscriber ID   Patient Name   Claim \\#   Total Charges   Service Dates    \nBilled In Error – Explanation    \nCPT / HCPCS Code Change From   To   Line(s)    \nDate of Service Change From   To   Line(s)    \nDenial Code (Remit) Correction  \nAmbulance Report Line(s)    \nDiagnostic Report Line(s)    \nEmergency Service Record Line(s)    \nInvoice Line(s)    \nItemized Bill Line(s)    \nOperative Report Line(s)    \nProgress Notes Line(s)    \nRecords Line(s)    \nTreatment Plan Line(s)    \nOther (Only if Not Listed Above)   Diagnosis Code Change From   To   Line(s)    \nDiagnosis Code Pointer Change From   To   Line(s)    \nDollar Amount Change From   To   Line(s)    \nHome Medical Equipment Item Returned Date of Return    \nModifier Change From   To   Line(s)    \nNew Provider Claim Submission From   To   Line(s)    \nPatient Name Change From   To   All Lines    \nProvider Number Change From   To   Line(s)    \nSubscriber ID Change From   To   All Lines    \nUnits Change – Decrease From   To   Line(s)    \nUnits Change – Increase From   To    \nWorker’s Compensation, Medicare, No Fault, Subrogation, Other Insurance   COVID   Telemedicine From   To   Line(s)    \n\n|  |\n| --- |\n| \u003Cbr>*THE FOLLOWING ADJUSTMENTS MUST HAVE SUPPORTING DOCUMENTATION\u003Cbr>*Appeal – Benefits From   To   Line(s)  \u003Cbr>*Appeal – Pricing From   To   Line(s)   |\n| INCOMPLETE FORMS WILL BE RETURNED WITHOUT REVIEW |\n\nContact Information Required Name   Phone Number   Ext.   \nPlease send completed form to:  \nBlue Cross Blue Shield of Wyoming  \nP.O. Box 2266  \nCheyenne, WY 82003  \nFax: 307-432-2942  \nPlease refer to your future payment listing for updates.  \n1. Please Include All Applicable: Case number, date of accident, subrogation information, and/or other insurance information, and other carrier’s explanation of benefits.  \n2. Exclude New Claims  \nRevised 01/04/2024","cbCaiuJag98OKK9g","https://ap.wps.com/l/cbCaiuJag98OKK9g","pdf",190813,"English","# Request for Professional Claim Adjustment\n## Adjustment Details (Line-Level Changes)\n## Required Supporting Documentation\n## Contact Information and Submission Instructions\n## Notes and Exclusions","[{\"question\":\"What must be included to adjust a professional claim?\",\"answer\":\"Include the rendering provider NPI and name, subscriber and patient identifiers, claim number, total charges, service dates, and the specific adjustment details with from/to values and line numbers where applicable.\"},{\"question\":\"Which adjustments require supporting documentation?\",\"answer\":\"The form states that the following adjustments must have supporting documentation, including appeal items for benefits and pricing (with line(s) specified).\"},{\"question\":\"How should the completed form be submitted, and what happens if it’s incomplete?\",\"answer\":\"Send the completed form to Blue Cross Blue Shield of Wyoming by mail or fax as listed. Incomplete forms are returned without review.\"}]","Request for Professional Claim Adjustment - Revised 01/04/2024 | PDF",1789563597]