Claim Adjustment Requests
To request a review of a previously adjudicated claim, print and complete the Claim Adjustment Request Form.
1. Use this form to request a review of a previously adjudicated claim.
2. Please provide all requested information to help expedite the processing of your request.
3. For “Type of Request”, please consider the following:
Primary EOP Submission – The claim originally denied for other coverage. You are submitting the primary carrier statement.
Not a Duplicate Charge – Submitting documentation to support reprocessing of charges that were initially denied as duplicate.
Timely Filing – Claim was originally submitted within defined time limits. Please ensure that your documentation clearly demonstrates proof of timely filing.
Itemized Bill Enclosed – Submission of requested charge itemization.
Overpayment Correspondence (check enclosed) – You are notifying us of an overpayment and are sending back the original check or a check in the amount of the overpayment.
Overpayment Correspondence (no check enclosed) – You are notifying us of an overpayment, but are not sending back the original check or a check in the amount of the overpayment.
Fee/Contract Schedule – You feel that the reimbursement you received was not in accordance with your contract/agreement.
Medical Necessity Appeal – Claim was denied as not covered due to medical necessity. You are submitting supporting documentation within 60 days of the original claim denial date.
Unlisted Procedure Code – Submission of supporting documentation for reconsideration of denied charges.
Medical Records Enclosed – Please do not submit medical records unless the claim denial specifically requests them.
If the claim does not fall into one of the above outlined categories, please contact the Provider Support Service Unit at 330-996-8400 or 800-996-8401.
4. If there are multiple claims that fall under the same “Type of Request”, please submit one form with an attached spreadsheet containing all of the requested information for each individual claim.
5. Instructions for submitting the completed form are found at the bottom of the form.
6. This form can be copied for future use. This form is also available at: Summacare.com on the Provider Homepage.
If you have multiple claims that fall under the same type of request, you may submit one form with an attached spreadsheet containing all of the requested information for each individual claim.
Submit completed forms to:
P.O. Box 3620
Akron, OH 44309-3620
Last Updated: 03/17/16