Adjustment Request Form – Medicaid 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. Add AttachmentsAccepted file types: pdf, Max. file size: 10 MB.Upload only PDF1. Please complete the following:You are submitting an Adjustment Request for ACCESS (Rite Care) / TRUST (Rhody Health Partners). To choose Integrity/Commercial, click here.Is this adjustment request for services that denied for EVV?*Is this adjustment request for services that denied for EVV? *Yes Note: Only providers rendering home care services should select “yes,” if applicable.NoMember ID #* 9 digitsMember Name* First Last Claim number* Beginning Date of service* MM slash DD slash YYYY Ending Date of service* MM slash DD slash YYYY Provider Name* NPI#* 10 digitsProvider Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact Name* Contact Phone*Contact Email* 2. Adjustment reasonSelect an Adjustment reason* Claim Processed Incorrectly NOPCP Denial Coordination of Benefits Retraction of Payment (indicate which claims) Duplicate Claim Timely Filing Limit Other: Specify Other Adjustment Reason*3. Description of request:*CAPTCHAIf you have any questions, please contact Provider Services at 800-963-1001. Thank you.