Adjustment Request Form – Integrity and Commercial

Please complete the electronic form below to submit a claim adjustment request.

To request an adjustment, the following items must be submitted for each individual claim:

  • A completed Adjustment Request Form
  • 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.

File Size: 10000KB Maximum

File Types: .pdf
1. Please complete the following:

You are submitting an Adjustment Request for Access/Trust/Unity. To choose Integrity/Commercial, Go back.

2. Adjustment reason:
3. Description of request:
* Required

If you have any questions, please contact Provider Services at 800-963-1001. Thank you.