Form 287H-HCW_overpayment_form - Oregon
|[pic] |OPI Adjustment Request | |
|Seniors and People with Disabilities |Overpayment form | |
|Branch # | |
|Date Completed (MM/DD/YY) | / / |
|Submitted by | |
|Phone # | |
|Worker email address: | |
|Client Name | |
|Client Prime # | |
|Provider Name | |
|Provider # | |
This is the Provider’s last voucher
USE HINQ SCREENS TO COMPLETE
NOTE: Some vouchers have several procedures on them. You must enter each procedure code, but you only need to enter voucher # and date once.
|Voucher # |Authorized |Authorized |Procedure Code and Description |Units Paid (hours)|Correct Units (hours) |
| |Begin Date |End Date |(For each voucher #, | | |
| |(MM/DD/YY) |(MM/DD/YY) |choose all that apply) | | |
| | / / | / / | | | |
| | / / | / / | | | |
| | / / | / / | | | |
| | / / | / / | | | |
| | | | | | |
Instructions to Add or Delete a Row:
Use floating SCREENS TOOLBAR. If you do not have the blue and grey floating toolbar, click “VIEW,” “TOOLBARS” & select “SCREENS TOOLBAR.”
Fraud
(Mark only if fraud was determined by SPD/AAA office or Medicaid Fraud Unit)
|Reason for Adjustment: |
Click here for submitting instructions
Submitting Instructions
Option #1:
( Prior to clicking the Submit Request button on the form, write down or copy email address listed below
• Click the Submit Request button
• Completed forms will automatically attach to the email
• Fill in the To section of the email with the email address below
• Send email
[pic]
Option #2: (Use this option if unable to use option #1)
( Save form
• Open Groupwise or other email system
• Attach form to email
• Send to address below
|Choose Email Address to Use |
|Groupwise Users |Users Outside of Groupwise |
|ProviderAdjustment, SPD |SPD.Provideradjustment@state.or.us |
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