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Get and Sign Form Map 2017-2022
Must be completed using the MAP EOB.
Important: All details from the MAP EOB must be included in the template even if a deductible or coinsurance
is not due.
The TMHP Standardized MAP Remittance Advice Notice template must be typed or computer-generated.
Handwritten forms will not be accepted and will be returned to the provider.
The following are the requirements for the Crossover Professional Claim Type 30 template:
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Field Description
Guidelines
0
MAP (Medicare
Part C)
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