Code of Maryland Regulations
Title 31 - MARYLAND INSURANCE ADMINISTRATION
Subtitle 10 - HEALTH INSURANCE-GENERAL
Chapter 31.10.12 - Uniform Consultation Referral
Section 31.10.12.08 - Uniform Consultation Referral Form - Required Forms

Universal Citation: MD Code Reg 31.10.12.08

Current through Register Vol. 51, No. 19, September 20, 2024

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

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

Uniform Dental Consultation Referral
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 dentist last name 18 203 220
17 - Primary/requesting dentist first name 12 221 232
18 - Primary/requesting dentist MI 1 233 233
19 - Primary/requesting dentist specialty 25 234 258
20 - Primary/requesting dentist institution/group name 80 259 338
21 - Primary/requesting dentist NPI # 10 339 348
22 - Primary/requesting dentist address 1 24 349 372
23 - Primary/requesting dentist address 2 24 373 396
24 - Primary/requesting dentist city 24 397 420
25 - Primary/requesting dentist state 2 421 422
26 - Primary/requesting dentist zip 9 423 431
27 - Primary/requesting dentist phone 10 432 441
28 - Primary/requesting dentist fax 10 442 451
29 - Specialist dentist last name 18 452 469
30 - Specialist dentist first name 12 470 481
31 - Specialist dentist MI 1 482 482
32 - Specialist dentist specialty 25 483 507
33 - Specialist dentist institution/group name 80 508 587
34 - Specialist dentist NPI # 10 588 597
35 - Specialist dentist address 1 24 598 621
36 - Specialist dentist address 2 24 622 645
37 - Specialist dentist city 24 646 669
38 - Specialist dentist state 2 670 671
39 - Specialist dentist zip 9 672 680
40 - Specialist dentist phone 10 681 690
41 - Specialist dentist 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 - Teeth diagram - attachment 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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