Claim Adjustment Requests
To request a review of a previously adjudicated claim, print and complete the Claim Adjustment Request Form .
Please provide all of the requested information on the form to help expedite the processing of your request. For "Type of Request," please consider the following types of requests:
Timely Filing – The claim was denied because it was not submitted within defined time limits. Please submit supporting documentation that indicates timeliness of filing with request form.
Fee/Contract Schedule – The reimbursement you received was not in accordance with your contract/agreement.
Procedure Code Audit – You disagree with the code audit results.
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.
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.
COB/EOP – The claim was denied because other insurance is listed as primary. Please submit primary carrier statement with request form or indicate a change in coverage.
Code Omitted form Original Claim – Resubmit new claim with correction(s).
Code Changed from Original Claim – Resubmit new claim with correction(s).
Medical Necessity Appeal – The claim was denied as not covered due to medical necessity; submit documentation along with appeal.
If the claim does not fall into one of the above outlined categories, contact Provider Support Services at 330-996-8400 or 800-996-8401.
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:
SummaCare, Inc.
Attn: Mailroom
P.O. Box 3620
Akron, OH 44309-3620
Fax: 330-996-8490
Email: contactproviderservices@summacare.com