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Revision:HCFAPM921 (MB) February 1992ATTACHMENT 2.6A Page 1STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: NEVADA Citation(s)ELIGIBILITY CONDITIONS AND REQUIREMENTS Condition or Requirement A.
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Start by entering the patient's personal information on the top section of the form, including their name, date of birth, and address.
02
Fill in the insurance information, including the policy number, group number, and the name of the insured party if it's different from the patient.
03
Next, provide details about the referring physician or practitioner, including their name, address, and NPI or provider number.
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In the diagnosis section, list the primary diagnosis code and any additional relevant codes if needed.
05
Use the procedure code section to enter the services or procedures provided to the patient, along with the corresponding dates and charges.
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If any supplies or medications were used during the visit, include them in the supply section along with the associated charges.
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Fill out the physician certification and signature section, providing the name, address, and NPI of the treating physician.
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Finally, review the completed form for accuracy and completeness before submitting it for reimbursement.

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hcfa-pm-92 - dhcfp is needed by healthcare providers, such as physicians, clinics, hospitals, and other healthcare facilities.
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It is used for billing purposes to submit claims for services provided to patients covered by the DC Medicaid program.
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Dentists, optometrists, and other healthcare professionals who are eligible to participate in the DC Medicaid program may also need to fill out this form.
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hcfa-pm-92 - dhcfp is a form used for submitting healthcare claims to the Department of Health Care Finance in the United States.
Healthcare providers and facilities that are seeking reimbursement for services provided to Medicaid beneficiaries are required to file hcfa-pm-92 - dhcfp.
hcfa-pm-92 - dhcfp should be filled out with accurate and detailed information regarding the services provided, patient details, and billing codes. The form can either be filled out manually or electronically.
The purpose of hcfa-pm-92 - dhcfp is to accurately report and document the healthcare services provided to Medicaid beneficiaries in order to seek reimbursement from the Department of Health Care Finance.
Information such as patient details, services provided, dates of service, billing codes, and provider information must be reported on hcfa-pm-92 - dhcfp.
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