Forms

• Form 130 (Claim-Level Adjustment Form) Print and complete this form to submit claim-level adjustment requests for paid Medicaid claims. (For use by providers who use legacy format to submit electronic Professional and Dental claims, and providers who use paper to submit Professional, Dental and Transportation Claims)


• Electronic Funds Transfer (EFT) Agreement
• Trading Partner Agreement 11/12/09
• Trading Partner Agreement Enrollment Instructions for Providers
• Trading Partner Agreement Enrollment Instructions for Vendors and Clearinghouses
• Disclosure of Ownership and Control Interest Statement SCDHHS Form 1514