31.10.12.08

.08 Uniform Consultation Referral Form — Required Forms.

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

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