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CLAIM APPEAL FORM

Details: the U.S. Department of Health and Human Services, Office for Civil Rights at 1-800-368-1019 or 1-800-537-7697 (TDD). Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de este plan de salud, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al . 1-844-396-0183.

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Living with Mental Health Issues

Details: A health care professional can do a number of things to rule out any underlying medical conditions that may be causing symptoms. You might be referred to a mental health professional who will use the “Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition” (DSM-5) to make a diagnosis.

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The Prior Authorization List

Details: Confidential and Proprietary Information of Avalon Health Services, LLC, d/b/a Avalon Healthcare Solutions PA-TOOL-6032-V02-20170124-Prior Authorization List 3 Procedure Code Description PA for 11/1/2019 81188 . CSTB (cystatin B) (e.g., Unverricht-Lundborg disease) gene analysis; evaluation to detect abnormal (e.g., expanded) alleles Yes

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PRESCRIPTION REIMBURSEMENT REQUEST FORM

Details: Parent is not enrolled in the same Group Health plan as the child 2. Parent does not reside in the same household as the subscriber under the child’s Group Health plan: If your child is covered under two or more health plans, state law determines the order of benefits for processing claims.

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