Adjustment Form
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1
2MEDICAID-TITLE XIX
BUREAU OF TENNCARE
STATE OF TENNESSEE
P. O. BOX 1700
AV
DEPARTMENT OF FINANCE
ADJUSTMENT/
NASHVILLE, TN 37202-1700
AND ADMINISTRATION
VOID REQUEST
IF YOU CHECK THIS BOX (b) PLEASE SEND THE REFUND CHECK
I.
Provider Information
AND THIS COMPLETED FORM TO:
State of Tennessee
a) ____________________________________
Bureau of TennCare, Floor 4 East
Attention: Fiscal Budget
Name
310 Great Circle Road
b) ____________________________________
Nashville, TN 37243-1700
Street Address
c) ____________________
TN
________
ALL OTHER COMPLETED ADJUSTMENT/VOID
City
State Zip
REQUESTS SHOULD BE SENT TO:
State of Tennessee
d) Provider No. _________________________
Bureau of TennCare
P.O.Box 1700
Nashville, TN 37202-1700
II.
a) Underpayment
b. Overpayment – refund check
c. Overpayment – Please deduct
from future claims payment
III.
Give Reason for Request:
IV.
TPL information – If AV request is due to third party payment, complete the following, or attach a copy of check
received:
a) Insurance Co. _________________________________ b) Policy # _____________________________
c) Name of Insured _____________________________ d) Claim # _____________________________
e) Amount Paid by Third Party ______________________ f) SSN # _______________________________
g) DOB______________________________________ h) Policy Termination Date________________
i) Policy Effective Date__________________________
V.
PLEASE ENTER THE FOLLOWING DATA FROM YOUR REMITTANCE ADVICE:
a)
Claim # __________________________________ b) Recipient ID#___________________________
c) Patient Name ___________________________________________________
Last
First
MI
d) Remittance Advice Date ____________________ e) Date of Service _________________________
f)
Billed Amount ____________________________ g) Paid Amount __________________________
FOR LTSS
Monthly Patient
PROVIDER
Liability Amount_____________________ Effective Date____________________
USE ONLY
VI.
I request that reprocessing of the claim be made with the information given above. I hereby certify that the
above claim for services is true and correct. I further understand and agree that the conditions on the reverse side
of this claim and conditions in the appropriate Provider Manual apply to this claim.
Signature _____________________________________________ Date ____________________________
Note: Please attach a corrected claim copy.
RDA 2909
TC-0139 (Rev. 4-17-15)
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