How to File a Void Request on a Paper Claim

Requirements for Filing a Void Request

A void request will be processed as a replacement to the original, incorrectly paid claim. When a claim is voided, the total payment for the original claim is deducted. There is no time limit on submitting a void. The provider can submit a paper void request on the remittance voucher, a legible photocopy of the
original claim, or an entirely new claim.

Voiding Claims on the Remittance Voucher

A claim can be voided by photocopying the remittance voucher and in black ink circling the claim to be voided. Write “void” on the side of the remittance voucher and briefly explain why the void is requested. Sign and date the remittance voucher in the margin. Only one claim can be voided per copy of the remittance voucher. Additional claims on the same remittance voucher must be voided by submitting additional photocopies of the remittance voucher. Each copy of the remittance voucher can only have one claim circled on it.

Voiding Claims on a Paper Claim Form

When requesting a void, the provider must:
·  Resubmit a photocopy of the original claim or a new claim form;
·  Enter the items listed on following page;
·  Initial and date the form if it is a photocopy, or sign and date it if it is a new
form; and

·  Mail the void request to the fiscal agent for processing to:
Adjustments and Voids
P.O. Box 7080
Tallahassee, Florida 32314-7080

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