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2023 Po Box 30783 Salt Lake City Ut 84130 Location 542
For Medica members with Payer ID #71890, 53589 or 88090, send the Claim Adjustment/Appeal Request Form with supporting documentation to: PO Box 30990 Salt Lake.
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Prior Authorization Form
form to fax 801-213-2132 SNF, Acute Rehab and LTAC Prior Authorization form. This form is not used for HOME Project Medicaid - please call 801-581-5515 or
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Providers Forms - Nevada Medicaid
Prior Authorization Forms. All prior authorization forms are for completion and submission by current Medicaid providers only. Form Number, Title. FA-
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