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Masshealth void request form

Form void request 2026

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The document is a Void Request Form from the Commonwealth of Massachusetts Executive Office of Health and Human Services, specifically for submitting requests to void claims other than pharmacy and dental. It outlines the procedure for completing the form, including attaching a photocopy of the remittance advice, specifying reasons for the void, and instructions for submission. The form also provides options for different types of claim issues and indicates that voided claims will be processed in future remittance advice.

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Click ‘Get Form’ to open the Void Request Form in the editor.
Begin by entering the 'Date of Request' at the top of the form. This helps track when your void request was submitted.
Fill in the 'Claim Form Type' and provide your NPI or Provider ID along with the Service Location. This information is crucial for identifying your claims.
Next, enter your 'Provider Name' and 'Provider Address'. Ensure these details are accurate to avoid processing delays.
List the 'Dollar Amount(s)' associated with each claim you wish to void. Be precise to ensure correct adjustments.
Select one reason for requesting the void from the provided options. If necessary, specify additional details in the 'Other' section.
Finally, sign in the designated area as 'Provider Authorized Signature' to validate your request before submission.

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Versions	Form popularity	Fillable & printable
2017	4.8 Satisfied (82 Votes)
2009	4 Satisfied (30 Votes)

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