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Get Toxicology Documentation 2020-2024

497 Contracted providers are subject to Appeal Timely Filing contract language. Non-Contracted Providers are subject to the UCM Default of (60) calendar days for Appeal Timely Filing in accordance OAC 5160-26.08.4(D)(1) and CMS Chapter 13 Section 50.1 *IF SUBMITTING A CLAIM ADJUSTMENT/CODING REVIEW REQUEST PLEASE DO NOT Provider Name: Medicaid ID: NPI: Phone: Contact Name: Fax: Date of Request: Member Name: Member ID: Place of Service: Member DOB: Claim Number: (1 claim per form) Authoriz.

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