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Get Palmetto GBA JM HH Pre-Claim Review Submission Request

K the appropriate box below: Initial Submission Resubmission Enter UTN of most recent submission: If this is a resubmission, each subsequent episode must be submitted on a seperate form. If this is a resubmission, do you have a copy of the most recent Non-Affirmation decision letter for this episode? Choose an item: Note: Use of this request document will require submission via fax, hard copy mail, or the electronic submission of Medical Documentation (esMD). To save time, use our eServices.

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