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Date Maximus Federal Services Inc 3750 Monroe Ave Suite 701 Pittsford NY 14534-1302 Re Request for Reconsideration Claim Number Beneficiary Medicare Number HIN SMC Account Number Date s of Service Provider Name Provider Telephone Number Provider Representative Dear Appeals Coordinator On xx/xx/xxxx the Hospital received a Medicare Redetermination Decision from Palmetto GBA dated xx/xx/xxxx. Educational references utilized by the Hospital include the CMS/QIO Manual Instructions QIO/Provider...
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