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  • Ohio Medicaid Repair Form - Reflection Medical

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Ohio Department of Job and Family Services CERTIFICATE OF MEDICAL NECESSITY/PRESCRIPTION REPAIR OF DURABLE MEDICAL EQUIPMENT (DME) SECTION A: Consumer/Provider Information Certification Type Initial.

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UB Used for surgical or general anesthesia-related supplies and drugs, including surgical trays and plaster casting supplies, provided in conjunction with a surgical procedure code. Modifiers UA and UB are mutually exclusive; therefore, only one modifier is allowed for each surgical procedure.

(5) The "U2" modifier must be used when the same provider submits a claim for billing code T1002, T1003 or T1019 for a second visit to an individual enrolled on the Ohio home care waiver for the same date of service.

Modifier 50 is used to report bilateral procedures (procedures described with the same CPT code) that are performed at the same operative session by the same physician on bilateral body structures (identical anatomic sites on opposite sides of the body).

Individuals with an existing Ohio Benefits Self-Service Portal account can log in and report changes. Visit ssp.benefits.ohio.gov. Select the “Access My Benefits” tile. Select “Report a Change to My Case” from the dropdown and follow the prompts.

Read the application carefully. Attach copies of your proof of income, resources (such as cash, savings, checking, real property, stocks, bonds, etc.), proof of citizenship or alien status, pregnancy if applicable, and other insurance you may have.

Modifier 59 is used to identify procedures/services, other than evaluation and management (E/M) services, that are not usually reported together, but are appropriate under the patient's specific circumstance.

UB indicates a second additional trip taken by the same individual on the same day in the same type of vehicle to or from the same type of location.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232