Maryland Uniform Referral Form

Maryland Uniform Referral Form - Maryland Uniform Dental Consultation Referral Form Referral Information Referral certification is not a guarantee of payment Payment of benefits is subject to a member s eligibility on the date that the service is rendered and to any other contractual provisions of the plan carrier

Maryland Uniform Consultation Referral Form Date of Referral Patient Information Name Last First MI Date of Birth MM DD YY Phone Member Site Carrier Information Name Maryland Physicians Care MCO Address 1 1201 Winterson Rd 4th Floor Linthicum MD 21090 Phone Number 800 953 8854 Referral certi cation is not a

Maryland Uniform Referral Form

Maryland Uniform Referral Form

After receiving approval, the specialist should complete the Uniform Consultation Referral Form. The Specialist must clearly indicate the PCP's approval on the referral. Exception: Specialists should directly refer members to participating providers for routine radiology, laboratory testing, rehabilitation, and DME services.

Submit the completed Uniform Consultation Referral Form to CareFirst BlueChoice applies to PCP only by fax to 410 505 6160 or 1 800 354 8205 Forms can also be mailed to Mail Administrator P O Box 14116 Lexington KY 40512 4116 This is not the correct form to refer a member for laboratory or radiology services

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Maryland Uniform Consultation Referral Form Primary or Requesting Provider Consultant Facility Provider Referral Information Referral certification is not a guarantee of payment Payment of benefits is subject to a member s eligibility on the date that the service is rendered and to any other contractual provisions of the plan carrier

Maryland Uniform Referral Form Fill Out And Sign Printable PDF Template SignNow

Maryland Uniform Consultation Referral Form PDF Maryland Uniform Credentialing Form PDF Medical Benefit Drug Prior Authorization Form PDF Member Pre Service Appeal Form PDF New Prior Authorization Form PDF Required Form as of 4 1 21 Please refer to Pharmacy PA Forms for medication requests Newborn Notification Form PDF

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Read Section 31 10 12 08 Uniform Consultation Referral Form Required Forms Md Code Regs 31 10 12 08 see flags on bad law and search Casetext s comprehensive legal database

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Maryland Code of Regulations Title 31 MARYLAND INSURANCE ADMINISTRATION Subtitle 10 HEALTH INSURANCE GENERAL Chapter 31 10 12 Uniform Consultation Referral the carrier shall use the uniform consultation referral form as defined in Regulation 02B 6 of this chapter B

Maryland Uniform Dental Consultation Referral Form Referral Information Referral certification is not a guarantee of payment. Payment of benefits is subject to a member's eligibility on the date that the service is rendered and to any other contractual provisions of the plan/carrier.

Patient Referral Specialist Maryland HealthChoice MedStar Family

The Maryland Uniform Dental Consultation Referral Form shall read as follows Click here to view Image B The electronic equivalent of the uniform consultation referral form is as follows Notes Md Code Regs 31 10 12 08 Regulation 08 adopted effective January 1 2005 31 23 Md R 1655 January 13 2011 38 1 Md R 12

Maryland Uniform Referral Form

Maryland Code of Regulations Title 31 MARYLAND INSURANCE ADMINISTRATION Subtitle 10 HEALTH INSURANCE GENERAL Chapter 31 10 12 Uniform Consultation Referral the carrier shall use the uniform consultation referral form as defined in Regulation 02B 6 of this chapter B

Maryland Uniform Consultation Referral Form Date of Referral Patient Information Name Last First MI Date of Birth MM DD YY Phone Member Site Carrier Information Name Maryland Physicians Care MCO Address 1 1201 Winterson Rd 4th Floor Linthicum MD 21090 Phone Number 800 953 8854 Referral certi cation is not a

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