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Get EDI Enrollment Form 2014-2024

Lectronic claim can be readily associated and identified with an original source document. Each source document must reflect the following information (except if not required for Section 1011): . • • • • • 7/21/2014 Beneficiary’s name; Beneficiary’s health insurance claim number; Date(s) of service; Diagnosis/nature of illness; and Procedure/service performed; V1.4 1 5. That the Secretary of Health and Human Services or his/her designee and/or the CMS contractor has the righ.

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