AGENCY: Department of Health. Division of Medicaid and Health Financing. Bureau of Authorization and Community Based Services

SERIES: 8127
TITLE: Gross adjustment form
DATES: 1985-
ARRANGEMENT: None

DESCRIPTION: This is an input form used to make corrections to the accounts of medicaid providers. It includes the identification number of the provider, the category of service, the accounting code, the recipient aid category and fund type, the dates of service, the county where the recipient is located, the amount of the adjustment and the reason for the adjustment, the date of approval, and the signature of the approving official.

RETENTION

Retain for 6 month(s)

DISPOSITION

Destroy.

RETENTION AND DISPOSITION AUTHORIZATION

These records are in Archives' permanent custody.

APPROVED: 08/1986

FORMAT MANAGEMENT

Paper: Retain in Office for 6 months and then destroy.

APPRAISAL

Administrative

After this information is input into the terminal, the form is sent to the Bureau of Medical Payments to be microfilmed with the medical claims. As the record is preserved on microfilm, the paper copy needs only be kept long enough to verify that the information has been correctly input into the data system.

PRIMARY DESIGNATION

Private