Complete the Payment Adjustment Form (DSHS 07-055) located in the WCAP. See the SSPS Manual Section 21-10 for instructions on how to complete the form.

Complete the Payment Adjustment form when a provider:

• Under bills the units on the invoice

• Requests first time authorization for care provided over 12 months ago (see section C. for how back the state can process a payment adjustment request).

A payment adjustment is not appropriate if the request is to increase units or rates. If the authorization line is:

• Open for the time period covering the increase. Make the change on the authorization line with a change effective date indicating the start of the increase. SSPS will send a new invoice. When the provider bills, SSPS will pay the difference between the old rate/unit and the increase.

• Closed for the time period covering the increase. Authorize new services for the requested time period. Authorize the difference between what was originally authorized and the increase.