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Get Passr Forms West Virginia

This form for the following situations: Shade Circles like this Not like this 1. If you received a Medicare Redetermination Notice (MRN) on this claim DO NOT use this form to request further appeal. Your next level of appeal is a Reconsideration by a Qualified Independent Contractor (QIC) (https://www.novitas-solutions.com/partb/forms/pdf/rrf/pdf). 2. If you received a message MA-130 on the Medicare Remittance Notice for this claim, no appeal or reopening rights are available. Please submit.

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