PROVIDER TRANSACTION ADJUSTMENT FORM
FOR USE BY PHARMACY PERSONNEL ONLY - ALL SECTIONS MUST BE COMPLETED
PREPARED BY
TITLE
EMAIL
PROVIDER NAME
PROVIDER NUM
JADEP PROVIDER NUM
UPLOAD FILE
ITEMS
+ ADD ITEM
- REMOVE ITEM
DATE OF TRANSACTION (mm/dd/yyyy)
RX #
MEMBER #
NDC #
QUANTITY
DAYS SUPPLY
TOTAL COST
REASON FOR ADJUSTMENT
TYPE OF ADJUSTMENT
Please select...
TRANSACTION ERROR
HOST PROCESSING ERROR
SYSTEM ERROR
BENEFICIARY NO LONGER NEEDS BENEFIT
INCORRECT DAYS SUPPLY
TO CORRECT DAYS SUPPLY
TRANSACTION NOT REFLECTING ON RX SYSTEM
INCORRECT ITEM SUBMITTED
REFILL TOO SOON
Please select...
REVERSAL
REPOST