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Get Medicaid Void Request Form 2018-2024

Justment to make changes to a previously paid claim. ï‚· Submit this form with a corrected CMS-1500, UB-04 or Dental claim form with red drop out ink and legal claim notice. ï‚· Include all attachments submitted with the original claim. ï‚· Adjustment requests must be submitted within 90 days from the date of the Remit Advice (RA) form the original paid claim. ï‚· Claims originally submitted via the web portal can be adjusted online (TCNs beginning with 9). VOID Select Void to cancel and.

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