Adjustment Request Form – Integrity

Please complete the electronic form below to submit a claim adjustment request. The following items must be submitted for each individual claim:

• Claim number
• Remittance Advice, Explanation of Benefits, or Coordination of Benefits documentation (as applicable)
  • Adjustment requests with claims attached will be returned to the sender.

If you have any questions, please call Neighborhood Provider Services at 800-963-1001.