31.10.12.06

.06 General Provisions.

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:

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 memberís eligibility on the date that the service is rendered and to any other contractual provision of the plan/carrier.