Adjustment Request Form

NEW – The Adjustment Request Form can now be completed online!

Adjustment requests can now be submitted electronically from our web site, rather than being mailed in. Simply complete the requested fields and add attachments, as necessary. If you have any questions, please call Provider Services at 800-963-1001.

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.