An EBT-4 is a form to make payment adjustments to providers when incorrect case information is transmitted to EPPIC and the provider is paid incorrectly.
- Determine if the incorrect payment was caused by a case issue, or by provider or client error
- An EBT-4 would be used in the event of a case issue, otherwise the provider would need to follow their manual claim process
- Use the chart to determine if an EBT-4 is required based on the date the case was corrected and the effective date of change
Effective Date of Change EBT-4 Required if Change is Made on or After This Date 01/01/2021 01/15/2021 02/01/2021 02/19/2021 03/01/2021 03/19/2021 04/01/2021 04/16/2021 05/01/2021 05/14/2021 06/01/2021 06/18/2021 07/01/2021 07/16/2021 08/01/2021 08/20/2021 09/01/2021 09/17/2021 10/01/2021 10/15/2021 11/01/2021 11/19/2021 12/01/2021 12/17/2021
- Confirm that an authorization is on the system for the time period you want to cover
- Confirm the appropriate changes are made in the system effective the 1st day of the current month
- Submit completed form to the EPS staff by clicking “Submit” at the bottom of the form