Fillable Printable Form 245-183-000
Fillable Printable Form 245-183-000
Form 245-183-000
F245-183-000 Provider’s Request for Adjustment 10-2017
Mail completed form to:
Department of Labor and Industries
PO Box 44269
Olympia WA 98504-4269
Provider’s Request
for Adjustment
• Submit one form for each ICN. Enter the information you want changed.
• Attach required reports and/or other documentation necessary to support your request.
• If your bill was denied in full, don’t use this form. Submit a new bill.
• Send corrected information to the address above.
• Send refunds only to the address on the next page.
• See complete instructions on the next page.
Reason for adjustment:
Total/partial overpayment
Partial underpayment
Bill information:
Worker’ name (last name, first name)
Claim number
L&I provider number or NPI
Provider name
ICN on remittance advice (17-digit number)
Information to be changed:
Line
item
no.
To/from date
of service or
covered dates
P
O
S
T
O
S
Procedure
code/revenue
code/NDC
Code
mod
ICD code
Tooth
no.
Charge
Days/
units/
qty
Days
supply
Description
Reason for adjustment:
Example: 2 units were billed in error; should have billed 6 units.
Signature:
Print name
Signature
Phone number
Date
RESET
F245-183-000 Provider’s Request for Adjustment 10-2017
Instructions for completing the Provider’s Request for Adjustment
Reason for Adjustment
Select reason for submitted adjustment.
Total/partial
overpayment
A total overpayment is when the entire bill was paid in error.
A partial overpayment is when a portion of the bill was overpaid.
You have two options to return the money to the department.
1. Complete and submit this form and the department will deduct the
overpayment from your future payments. Mail the form to the address on the
previous page.
2. You may repay the money to the department. Send your check with the a
copy of the remittance advice to:
Department of Labor and Industries
Cashiers Office – MIPS Deposit
PO Box 44835
Olympia WA 98504-4835
Underpayment
Complete an Adjustment Request for each ICN that you think was underpaid with
the correct information for the procedures/items. Attach any required reports and/or
other documentation to support your request.
Bill information:
Worker’s name
Enter the worker’s name in the last name, first name, middle initial
format.
Claim number
Enter the claim number for the worker. The claim number can be
found in the Claim Number column of the remittance advice.
Provider’s name
Enter the name of the provider who performed the services.
L&I provider number or NPI
Enter the L&I provider number or NPI for the provider who performed
the services.
ICN
Enter the 17-digit number found in the ICN column of the remittance
advice for the procedure/item you are adjusting.
Information to be changed:
Line item no.
Enter the line item number(s) from your original bill that you want to
correct.
To/from date of service or covered
dates
Date of service, to and from date if date span, or admit and
discharge date for hospital bills.
POS
Two-digit code identifying the place of service.
TOS
One-digit code identifying the type of service performed.
Procedure code/revenue code/NDC
Enter the correct procedure, hospital service, or national drug code.
Code mod
Enter the correct modifier used to identify special circumstances for a
procedure or service.
ICD code
Enter the ICD code for condition treated. Enter side of body if
applicable.
Tooth no.
For dental services only. Enter the two-digit code identification
number for the specific tooth number treated.
Charge
Total charge for services provided for this line only.
Days/units/quantity
Total days stayed for hospital accommodation codes, units of service
for procedure (time units, miles, etc), or number of items (tablets,
milliliters, etc).
Days supply
For pharmacy services only. Total number of days a prescription is
intended to cover.
Description
Description of the procedure or services provided.
