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Request for Claim Adjustment Instructions

How do I file an adjustment to a claim?

Complete a Professional or Institutional Claim Adjustment Request Form.

The following requests require medical documentation:

  • Procedure code changes
  • Diagnosis code changes
  • Diagnosis code pointer changes
  • Units of services changes
  • Modifier changes

The following requests do not require medical documentation:

  • Dollar amount changes
  • Additional or adjusted charges

Additional information needed to ensure timely processing:

  • Include the date of service and claim number of the claim which you are requesting the change.
  • Please give a detailed explanation of changes you are requesting.
  • When submitting chart notes or medical information, submit an explanation of why this information is being submitted. If the information being submitted was requested by Blue Cross Blue Shield of WY, please attach a copy of the request.
  • When submitting claim appeal letters, please attach supporting documentation (chart notes, x-ray reports, etc.).
  • The Request for Professional Claim Adjustment form should be used for services submitted on a CMS-1500.
  • The Request for Institutional Claim Adjustment form should be used for services submitted on a UB-92.
  • Include the full name (first and last name) and telephone number of the person submitting the adjustment request.
  • Submit only one claim per inquiry form.
  • When using these forms, enter the total amount of the claim prior to the adjustment.

Send written request to:

PO Box 2266
Cheyenne, WY 82003

Fax requests to: (307) 432-2942

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