​If you have received an incorrect claims payment or received a payment from a third party after receiving payment from Medicaid, to correct the payment you must complete and submit an adjustment request form.

• Single Claim Adjustment Request Form 4518A
• Multiple Claim Adjustment Form 4567​
  

Submit Claim Adjustment Request Form

• You must submit and attach any supporting documentation to the adjust request form, for example a remittance advice and CMS-1500 claim forms. 
• Mail adjustment request form and supporting documentation to the Medical Assistance Adjustment Unit.
• For additional guidance and examples, refer to the CMS-1500 Billing Manual.

Contact

For more information or questions, call the Adjustment Unit​.