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Est adjustment of claim payment received that does not correspond with payment expected. Adjustment Requests must be submitted within 67 calendar days of the original determination of the claim (the date of your Explanation of Payment or EOP). All fields in the box immediately below are required information Provider name: Provider Tax ID Number: Control Number: Date(s) of Service: Member Name: Member (RID) Number: Reason for Adjustment Request (please check): Claim was denied for no author.

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