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Practitioner and Provider Complaint and Appeal Request NOTE: Completion of this form is mandatory. To obtain a review submit this form as well as information that will support your appeal, which may include medical
CMS SPECIALTY CODES/HEALTHCARE PROVIDER TAXONOMY CROSSWALK This document “walks” the CMS Medicare specialty codes to the taxonomy codes currently maintained by the Washington Publishing Company as mandated by the Health Insurance
Provider Enrollment Applicant Reference Form 06/01/13 Page 1 of 1 . PROVIDER APPLICANT REFERENCE FORM The applicant below has applied to become a Medicaid Waiver Provider.
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