(RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) 22. 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 ...
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 ...