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Form 12203 Dayton Ohio: What You Should Know

A one-page form that provides a claim Form 2453 — Claims for Coverage Denied to Employee Claim for Coverage Denied form (Form 2555) (for non-Medicare or Government programs) Claim for Coverage Denied form (Form 2454) (for other programs) If you have a question in regard to the level of care/career reassignment services required, you can contact our claim review team by phone at, TTY, or E-mail. We cannot provide the level of care/career reassignment services through the mail. You have one year to submit your completed claim and the level of care/career reassignment services required to the claimant's Medical Review Office. The medical review office may require medical records in addition to any claim files in order to assess your claim. If the claimant does not receive any medical documents or the medical records can no longer be located by the claimant within 1 year of the submission date, your claim will not be accepted. Medicare Claim Review | Claimants are not responsible for filing the form(s) for the Level of Care Affirmation For questions about Medicare claims review, contact our Medicare claims review team by phone at, TTY, or E-mail. For all cases where the Medicare claims review is required, you must submit both forms in the enclosed envelope. Please remember to include a completed Form 2453 Claim for Coverage Denied to Employee as well as and claim form, if appropriate. Form 2453 Claim for Coverage Denied to Employee (Form 2555) Form 2454 Claim for Coverage Denied to Employee (Form 2454) If you have a question or concern on whether a particular claim is a health expense deductible, contact our level of care team at, TTY or E-mail. The Medicare claims review office can require medical records in addition to any claim files in order to assess your claim. If the claim can no longer be located by the beneficiary within 1 year of the submission date, and the claim contains an “H” for Human or Animals (in this case the appropriate form must be filed as well), your claim will not be accepted.

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