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Get HI Form 239 2014-2024

Er Number 4. Address: ☐Pay to Address ☐Service Address 5. Telephone Number 6. Name of Contact 7. Claim Number (if applicable) 8. Purpose of Inquiry: ☐Questionable Payment ☐Claims Filing Procedure ☐Claim Status ☐Other * Do not use this form for claim adjustments. Send resubmissions to the appropriate Hawaii Medicaid Fiscal Agent Claim PO Box. 9. Patient Name 10. Patient ID Number 11. Dates of Service 12. Payment Date 13. Charge 14. Allowance 15. Remarks 16. Response to .

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Keywords relevant to HI Form 239

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  • reprocessing
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  • DEPT
  • blvd
  • medicare
  • medicaid
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