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Is to be attached to the top of each CMS1500 and must be completed in its entirety before submission of the claim. Inaccurate/Incomplete Cover Sheets will not be processed and will be returned for correction. 1. Medicaid Assigned Carrier Code enter the six- (6) digit carrier code assigned to the Medicare Advantage provider. All codes begin with H. and end with a trailing 0.(zero). 2. Medicare Paid Date enter the date of the Medicare Advantage Carrier Explanation of Benefits. 3. Medicai.

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