Claim adjustment

Adjustment reason requests include additional or corrected data that was not on the original claim.

Use our Quick Claim Submission Guide to review guidelines for common claim scenarios.

Minnesota Statute section; 62J.536 requires Minnesota providers to submit adjusted claims in the electronic 837 format.

Adjustment reason

* Please check applicable reason

Documentation supporting your adjustment is required.

Provide a description of the corrected coding.

Documentation supporting your adjustment and description are required.

Description supporting your adjustment is required.
Description supporting your adjustment is required.

Provider information

*

Contact information

Claim information

$

Supporting information

Attach documentation to support your request

The file/s have been attached and will be submitted with this form, but the attached file names are not available to display at this time.

You may continue and submit this form if you have attached the appropriate documentation, or click cancel to start over.

{{attachment.filename}}

Less than one Megabyte attached (Maximum 20MB) {{totalAttachLength | number:2}} Megabytes attached (Maximum 20MB)
  • bmp (Bitmap-image file)
  • csv (Comma-delimited data/spreadsheet)
  • doc
  • docx
  • gif (Image file)
  • jpeg (Image file)
  • jpg (Image file)
  • odt (OpenDocument text file)
  • pdf
  • png (Image file)
  • psd (Photoshop image file)
  • rtf (Text file)
  • tif (Image file)
  • tiff (Image file)
  • txt
  • xls
  • xlsx
  • xml (Data file)
  • xps