Code of Maryland Regulations
Title 31 - MARYLAND INSURANCE ADMINISTRATION
Subtitle 10 - HEALTH INSURANCE-GENERAL
Chapter 31.10.12 - Uniform Consultation Referral
Section 31.10.12.06 - General Provisions

Universal Citation: MD Code Reg 31.10.12.06

Current through Register Vol. 51, No. 26, December 27, 2024

A. The requirements under these regulations do not apply to an entity that would be using a consultation form solely for internal purposes.

B. The Maryland Uniform Consultation Referral Form shall read as follows:

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C. The electronic equivalent of the uniform consultation referral form is as follows:

Electronic Equivalent of the Uniform Consultation Referral Form
Field Length Start Stop
1 - Patient last name 18 1 18
2 - Patient first name 12 19 30
3 - Patient MI 1 31 31
4 - Patient DOB 8 32 39
5 - Patient phone number 10 40 49
6 - Patient member number 16 50 65
7 - Patient site number 10 66 75
8 - Carrier name 24 76 99
9 - Carrier address 1 24 100 123
10 -Carrier address 2 24 124 147
11 - Carrier city 24 148 171
12 - Carrier state 2 172 173
13 - Carrier zip code 9 174 182
14 - Carrier phone number 10 183 192
15 - Carrier fax number 10 193 202
16 - Primary/requesting provider last name 18 203 220
17 - Primary/requesting provider first name 12 221 232
18 - Primary/requesting provider MI 1 233 233
19 - Primary/requesting provider specialty 25 234 258
20 - Primary/requesting provider institution/group name 80 259 338
21 - Primary/requesting provider NPI # 10 339 348
22 - Primary/requesting provider address 1 24 349 372
23 - Primary/requesting provider address 2 24 373 396
24 - Primary/requesting provider city 24 397 420
25 - Primary/requesting provider state 2 421 422
26 - Primary/requesting provider zip 9 423 431
27 - Primary/requesting provider phone 10 432 441
28 - Primary/requesting provider fax 10 442 451
29 - Consultant/facility provider last name 18 452 469
30 - Consultant/facility provider first name 12 470 481
31 - Consultant/facility provider MI 1 482 482
32 - Consultant/facility provider specialty 25 483 507
33 - Consultant/facility provider institution/group name 80 508 587
34 - Consultant/facility provider NPI # 10 588 597
35 - Consultant/facility provider address 1 24 598 621
36 - Consultant/facility provider address 2 24 622 645
37 - Consultant/facility provider city 24 646 669
38 - Consultant/facility provider state 2 670 671
39 - Consultant/facility provider zip 9 672 680
40 - Consultant/facility provider phone 10 681 690
41 - Consultant/facility provider fax 10 691 700
42 - Reasons for referral 80 701 780
43 - Brief history, dx, results or attachment 120 781 900
44 - Service desired - code 2 901 902
45 - Place of service - code 2 903 904
46 - Number of visits 2 905 906
47 - Authorization number 10 907 916
48 - Referral validity date 8 917 924
49 - Signature/electronic person completing the form 30 925 954
50 - Authorized signature/electronic 30 955 984
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 provision of the plan/carrier.

Disclaimer: These regulations may not be the most recent version. Maryland may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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