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
Professional Claim Adjustment Information
Provider Name Individual Provider NPI
Patient Name Date of Birth (MM/DD/YYYY)
Benet Plan Number Patient Account Number
From Date Through Date
Claim Number Total of Original Claim
Reason for Adjustment From To Line(s) to Adjust
Benet Plan Number Change All lines
Patient Name Change All lines
Date of Service Change
Dollar Amount Change
Provider NPI Change
Place of Service Change
Billed in Error
Home Medical Equipment Item
Coordination of Benets
(EOB attached)
*Modier Change/Addition
*Diagnosis Code Change/Addition
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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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Professional Claim Adjustment
Reason for Adjustment From To Line(s) to Adjust
*Units Change
*CPT/HCPCS Procedure
Code Change
*Diagnosis Pointer Change
Other (Please explain)
*Supporting medical documentation is required.
Contact Information
Contact Phone Number Date
29379444 • 1-20
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