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recipient eligibility verification

Step 2 of 2 Please print this page for your records. For questions please contact Provider Relations at: 410-767-5503 or 800-445-1159

9/4/2018 11:16:50 AM Reference number: 76071611

Inquiring provider: 402824400

RECIPIENT INFORMATION

MA number: {{redacted}} SSN: {{redacted}}

Recipient name: RUGH

ELIGIBILITY INFORMATION

For 9/4/2018 12:00:00 AM ELIGIBLE for date of service Recipient's Re-Determination Date is 10/31/2018

Citizenship verified

Identity verified

DHR/FIA form 9709S must be completed if long term care services are required

BENEFIT DESCRIPTION

Recipient is SLMB only Medical Assistance only covers recipient's Medicare Part B premium payment.

BENEFIT EXCLUSIONS

BENEFIT LIMITATIONS

OTHER PAYORS

FACILITIES

recipient eligibility verification

Step 2 of 2 Please print this page for your records. For questions please contact Provider Relations at: 410-767-5503 or 800-445-1159

9/4/2018 11:16:50 AM Reference number: 76071611

Inquiring provider: 402824400

RECIPIENT INFORMATION

MA number: {{redacted}} SSN: {{redacted}}

Recipient name: RUGH

ELIGIBILITY INFORMATION

For 9/4/2018 12:00:00 AM ELIGIBLE for date of service Recipient's Re-Determination Date is 10/31/2018

Citizenship verified

Identity verified

DHR/FIA form 9709S must be completed if long term care services are required

BENEFIT DESCRIPTION

Recipient is SLMB only Medical Assistance only covers recipient's Medicare Part B premium payment.

BENEFIT EXCLUSIONS

BENEFIT LIMITATIONS

OTHER PAYORS

FACILITIES

Reason of review: Problems with payment.

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