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866-376-2921 and report applicable clinical

Humana/LifeSynch does not currently use such a form for behavioral health.
However, OrthoNet, a contracted disease management vendor for Humana, does

Provider Enrollment and the Patient Protection and Affordable – CAQH

Oct 20, 2011 … 13 states have unique credentialing application forms supported by UPD. –
Remaining states … The average health plan enrollment forms contain the same
elements, e.g., Name, Provider. Type ….. Humana / ChoiceCare Network.
Humana … OrthoNet. Oxford Health Plans, Inc. Paragon Health Network.

Commonwealth Coordinated Care – DMAS Portal

Humana. • Virginia Premier. • CCC is an enhancement over regular. Medicare/
Medicaid ….. forms (not black and white or photocopied forms) and laser printed
or …

EOB Code Description – Washington State Department of Labor and …

Fee for service includes office call. NULL. CO. P13. NULL. 065 Only one
adjustment form should be submitted listing all changes requested to an ICN bill.

IN Prior Authorization Form – Cigna

Prior Authorization Request Form for Health Care Services for Use in Indiana.
Section I — Submission. Issuer Name. Phone. Fax. Date and Time Submitted.

1 – State of Michigan

Dec 31, 2015 … Page 1. JURAT. (732450./30./../..(. HEALTH ANNUAL STATEMENT. FOR THE

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