(Revised 9/00 ML #2584)
This form is generally used by Medicaid service providers and, in fact, will be used by basic care providers. However, when a county discovers that an error has occurred in computing the "Resident Payment Amount" the county currently managing the case file is required to contact the Claims Processing Unit in the Medicaid Division. This form will be used to make corrections.
This form is available through the Department of Human Services and may also be obtained electronically via E-Forms. (100kb pdf)
