Use this form to adjust a claim that processed in the BCBSND legacy system. Claim Adjustment is the appropriate process for
the following members: 1) Host (out-of-area) members with a date of service (DOS) prior to July 1, 2018; 2) FEP members (prex
of R) with DOS prior to September 1, 2018; or 3) BCBSND members with any of the following prexes: BSB, DDU, DEW, OTO,
RDO, SHV, THI, TNT, USZ, YQA, YQB, YQC, YQE, YQG, YQI, YQJ, YQP, YQQ or YQU with a DOS prior to January 1, 2019. Use the
Claim Correction process for all other claim adjustments/corrections.
Return completed forms by:
ATTN: Provider Service
4510 13th Ave. S.
Fargo, ND 58121
Fax: 701-277-2132
Institutional Claim Adjustment Information
Provider Name Provider NPI
Patient Name Date of Birth (MM/DD/YYYY)
Benet Plan Number Patient Account Number
Admission Date From Date Through Date
Claim Number Total of Original Claim Corrected Total
Reason for Adjustment
Revenue Code CPT/HCPCS Date of Service Units Amount
*Late Charge
*Late Credit
Institutional Claim Adjustment
29379445 • 1-20
Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross & Blue Shield Association
Noridian Mutual Insurance Company
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Reason for Adjustment (Continued)
From To
Benet Plan Number Change
Patient Name Change
Billed in Error
Coordination of Benets
(EOB attached)
*Revenue Code Change
*Units Change
*CPT/HCPCS Procedure
Code Change
*Modier Change/Addition
*Diagnosis Code Change/Addition
Other (Please explain)
*Supporting medical documentation is required. (Changes to revenue codes 036X, 0278, 075X and 049X require the operative report for review.)
Contact Information
Contact Phone Number Date
29379445 • 1-20
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