MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. 1. 3. 23. PRIOR AUTHORIZATION NUMBER 2. 4. 24. A B C D E F G H I J K N DATE(S) OF SERVICE Place Type PROCEDURES, SERVICES, OR SUPPLIES DAYS EPSDT RESERVED FOR O From To of of (Explain Unusual Circumstances) DIAGNOSIS OR Family I ...
resubmission OPTIONAL No entry required. 23 Prior authorization number SITUATIONAL REQUIRED if there is a prior authorization, enter the prior authorization number. Obtain the prior authorization number from the prior authorization form. 24A. Date(s) of ...
accordance with the provisions of California Code of Regulations (CCR), Title 22 and policies established by the Department of Health Care Services. claim sub 7 1– Claim Submission and Timeliness Overview December 2009 Resubmission Turnaround A Resubmission Turnaround Document (RTD) is sent to pro...
NOTE:Ifclaim(s)alsorequiredacorrection,suchasavalidprocedurecode,locationcodeormodifier,includeacopyofthatpagefromyourEOPwiththeclaimcircled,alongwithacopyofthenew,correctedCMS-1500orUB-04form,marked“RESUBMISSION”acrossthetop. Mailcompletedform(s)andattachmentsto: ...