Va Premier Claim Adjustment Form

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Va premier claim adjustment form. Claim Adjustment Request Form VPHP01. All reconsiderations must be submitted in writing on the Virginia Premier Claim Adjustment form via mail within 60 days of the provider remittance date. Our secure provider portal is available 24 hours a day to assist you with accessing data quickly and easily. Box 27401 Richmond VA 23279-7401.

Department of Veterans Affairs Claims Intake Center PO Box 4444 Janesville WI 53547-4444. Please ensure all fields on the form are completed and attach detailed information explaining the reason for the refund. The portal is free of charge for all participating providers. CMS1500 UB 04 Date Sent.

Download VA Form 21-0966 PDF Turn in your form in any of these ways. Please complete all sections of this form to assist us when researching your inquiryadjustment request. Provider Name and Address. Provider Name and Address.

For questions please contact Claims Customer Service at 1-800-727-7536. Office Inpt Hospital. Should you want to receive the EDI 835 ERA Electronic Remittance Advice from Virginia Premier the process is exactly the same as the process to send electronic claims to Virginia Premier. Prescription Medication Claim English PDF Prescription Medication Claim Spanish PDF Prescription Medication Precertification Opioid addiction treatment.

Corrected Claim submissions do need to contain the correct billing code to help us identify when a claim is being submitted to correct or void a claim that weve previously processed. Claim Adjustment Form Providers who want to appeal a claim outcome need to submit a corrected claim or request a retraction due to a payment error need to do so using the Claim Adjustment form. Mail it to this address. Virginia Premier is dedicated to providing you with great service.

Virginia Premier Claims PO Box 5286 Richmond VA 23220 Phone 1-804-819-5151 Toll Free 1-800-727-7536 Provider Name. Claim Adjustment Request Form VPHP01. Toll Free1-800-727-7536 Provider Name. Please make a selection for the linkdocumentation desired.

On the following information pages 2 through 7. Virginia Premiers Provider Portal is a safe and secure tool that gives providers quick and easy access to. Virginia Premier Claims PO Box 5286 Richmond VA 23220. For Federal Employee Program use.

. Claim Adjustment Request Form VPHP01. For Aetnas commercial plans there is no precertification required for buprenorphine products. The following is the list of available options within this category.

Provider Updates You can inform us of provider changes and updates by submitting a request form online at. Box 105557 Atlanta GA 30348-5557. Paper Claim Submission Addresses. If you are making a claim for survivor benefits use VA Form 21P-534EZ Application for DIC Death Pension andor Accrued Benefits.

Providers who want to appeal a claim outcome submit a corrected claim or request a retraction due to a payment error should use the Claim Adjustment form. Download fill out and submit an Intent to File a Claim for Compensation andor Pension or Survivors Pension andor DIC VA Form 21-0966. Please describe problem and requested action. Click here to enter text.

The EDI 837 Electronic Claims Enrollment form can be found in the Claims section of the Provider Forms Library. Click here to enter text. Virginia Premier no longer asks providers to stamp or write corrected claim on the CMS- 1500 paper claim form. The Provider Refund Form will assist Virginia Premier with handling your refund inquiries expeditiously.

Please Mail Form To. Click here to enter text. Provider Refund Form The Provider Refund Form will assist Virginia Premier with handling your refund inquiries expeditiously. If you are making a claim for veterans non service-connected pension benefits use VA Form 21P-527EZ Application for Pension.

Please see the Medicare section of this page.