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To request corrections to authorizations that have been approved for dates of service on or after 7/1/2020, please complete the following information:

Please note that initial and retro authorization requests will not be accepted through this box.

 

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Name of the person submitting the claim
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Email address of the submitter
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Phone number of the person submitting the form
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This name must be exactly as it appears on the service request.
Provider Site

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Only one service request id per request
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 All
 Specific CPT / Rev Codes
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 Wrong Start Date
 Wrong provider address chosen
 Wrong units entered (and no clinical review for additional units required)
 Forgot to add a code to request
 Other
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