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MMS ATTACHMENT COVER SHEET Clear Fields NORTH DAKOTA DEPARTMENT OF HUMAN SERVICES MEDICAL SERVICES DIVISION SON 177 (62015) Complete this form and include it as the cover sheet for all attachments
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How to fill out mmis attachment cover sheet

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How to fill out the MMIS attachment cover sheet:

01
Start by gathering all the necessary information. This includes the details of the attachment you are submitting, such as the type of document, the date, and any other relevant information.
02
Begin filling out the top section of the cover sheet. This typically includes fields for the provider's name, address, contact information, and the provider's identification number or NPI.
03
Move on to the next section, which is usually labeled "Attachment Information." Here, you will need to provide specific details about the attachment, such as the attachment control number, the type of document being attached, and a brief description or summary of the attachment.
04
If applicable, fill out the section for "Authorization." This section may ask for the signature and date of the authorized individual who is submitting the attachment.
05
Double-check all the information you have entered to ensure accuracy and completeness. Make sure to review any guidelines or instructions provided by the MMIS to ensure you have followed all the necessary steps.
06
Submit the completed attachment cover sheet along with the required documents to the designated recipient or entity specified by the MMIS.

Who needs the MMIS attachment cover sheet?

The MMIS attachment cover sheet may be required by healthcare providers, such as hospitals, physicians, clinics, or any other entities that are submitting attachments or supporting documents to the Medicaid Management Information System (MMIS). This cover sheet helps streamline the attachment submission process and ensures that the necessary information is properly documented and associated with the corresponding attachment.
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MMIS attachment cover sheet is a form used to provide additional information and documentation with a claim submission in the Medicaid Management Information System (MMIS).
Providers submitting claims with attachments are required to file MMIS attachment cover sheet.
Providers must fill out the required fields on the MMIS attachment cover sheet including provider information, recipient information, claim details, and description of attached documents.
The purpose of the MMIS attachment cover sheet is to ensure that all necessary information and documentation are properly submitted and linked to the corresponding claims in the MMIS.
Provider information, recipient information, claim details, and a description of attached documents must be reported on the MMIS attachment cover sheet.
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