ADJUSTMENT VOID Request Form - New Mexico Medicaid Portal 2025

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4.4 out of 5

182 votes

The document provides instructions for submitting Adjustment or Void requests for paid claims in the New Mexico Medicaid Program. It outlines the necessary information required, including provider details, claim history, reasons for adjustment or void, and actions needed. It emphasizes that adjustments can only be made on paid claims and must include proof of timely filing if applicable. The document also includes a request form and best practices for submission.

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Click ‘Get Form’ to open the ADJUSTMENT VOID Request Form in our editor.
Begin by checking the appropriate box for either 'Adjustment' or 'Void'. Remember, an adjustment changes information on a paid claim, while a void recoups the entire payment.
In the Provider Information section, enter your NPI or NM Medicaid billing provider number and check the corresponding box. Fill in your facility name, phone number, and mailing address.
For History Information, accurately input details from your NM Medicaid Remittance Advice. Ensure that the TCN is exactly as printed and limited to 17 digits.
Provide a brief description of your Adjustment/Void Reason. Be clear and concise; for example, state 'Billed incorrect units.'
List any specific box numbers and line numbers that need changes in the Action Needed section to facilitate processing.
If applicable, indicate if you have been overpaid by checking one of the options provided.
Sign in the Authorizing Signature space and enter the date authorized.

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Versions	Form popularity	Fillable & printable
2018	4.8 Satisfied (56 Votes)
2017	3.9 Satisfied (32 Votes)
2007	4.4 Satisfied (182 Votes)

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is the maximum income to qualify for Medicaid in New Mexico?

To appeal an issue related to Medicaid or the Childrens Health Insurance Program (CHIP), contact the New Mexico Human Service Department (HSD). You can find more information about Medicaid in New Mexico. Apply for Medicaid online. Get Medicaid assistance in your area.

How do I check status of Medicaid?

Log into your states Medicaid portal Many states have online portals where you can check your Medicaid coverage status. If you already created an account when you applied, log in to see any updates or changes to your status. Look for a section that shows your coverage details or current eligibility.

How do I contact the Medicaid portal in New Mexico?

If you continue to have problem accessing the chat icon call, Customers can call 1-800-283-4465 and Providers can call 1-800-299-7304.

How do I check the status of my Medicaid application in New Mexico?

You can also get information about the status of your application and benefits by calling our automated response line at 1-800-283-4465. It may take us up to 30 days to process your application for some food assistance or other benefits programs, and it may take up to 45 days to process your application for Medicaid.

What is the highest income to qualify for Medicaid in New Mexico?

As of January 1, 2024, the maximum allowable countable income limit is $2,829 per month. (Persons with less than $50 in income must apply for SSI). The resource limit for single individuals for this program is $2,000.