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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

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


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