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Get HI Form 240 2014-2024

Nt amounts for specific services. Please limit your reconsideration requests to one claim per Form 240. All fields on Form 240 are required and must be completed. Upon completion, please send Form 240 and any attachments to Hawaii Medicaid Fiscal Agent, 1132 Bishop St., Suite 800 Honolulu, HI 96813. Upon receipt, we will conduct the preliminary research to verify that the claim was processed and paid in accordance with Medicaid policy. Claims processed incorrectly will be submitted for reprocess.

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