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The document is a form from the Wisconsin Department of Health Services, specifically for the Division of Medicaid Services, detailing the Explanation of Medical Benefits. It provides structured sections for payer information, member details, primary policyholder information, and adjudication information related to medical claims. The form is intended for providers to submit claims and includes instructions for completion.

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Versions	Form popularity	Fillable & printable
2018	4.8 Satisfied (99 Votes)
2014	4 Satisfied (26 Votes)

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