Forms

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Across
  1. 2. CIF stands for Claim __ Form
  2. 5. Members do not receive a TARNOT if all treatment was __
  3. 8. this document is valid for 365 days (Acronym)
  4. 13. EOB stands for __ of benefits
  5. 16. Members get a TARNOT if treatment is denied, __ ,or modified
  6. 18. A CIF is most commonly used for claim__
  7. 19. CIFs must be sent within __ months on the most recent EOB
  8. 20. Providers send this to request authorization for treatment (abbrev)
  9. 22. HLD is the Handicapping Labio-lingual __ index
  10. 23. RTD stands for Resubmission __ Document
  11. 24. A completed NOA or a __ form is used to bill completed treatment
Down
  1. 1. Sample forms can be found in the Provider
  2. 3. if a member is billed for a covered service an __ billing letter is sent
  3. 4. A retroactive reimbursement request
  4. 6. NOAs are sent to __ only
  5. 7. The __ Data Record is part of the Conlan Packet
  6. 9. DCN stands for Document __ Number
  7. 10. This form must be sent with an orthodontic TAR (Acronym)
  8. 11. Providers have __ days to respond to an RTD (two words)
  9. 12. Complaints may be filed over the phone or using the form found the __ website
  10. 14. the DC-054 form is the Justification of Need For __
  11. 15. NOA stands for Notice of ___
  12. 17. Providers see CalAIM and Prop 56 payments on their __
  13. 21. A TARNOT is a Notice of Medi-Cal Dental __