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RegulationCOMAR 31.10.12

Chapter 12 Uniform Consultation Referral

Maryland · Insurance Administration
First seen July 20, 2026 · last checked July 21, 2026
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Chapter 12 Uniform Consultation Referral | Library of Maryland Regulations
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Library of Maryland Regulations
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Code of Maryland Regulations
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Title 31 MARYLAND INSURANCE ADMINISTRATION
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Subtitle 10 HEALTH INSURANCE — GENERAL
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Chapter 12 Uniform Consultation Referral
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Code of Maryland Regulations
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Chapter 12 Uniform Consultation Referral
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Administrative History Effective date: October 21, 1996 (23:21 Md. R. 1467) Regulation .03 amended as an emergency provision effective January 28, 1997 (24:4 Md. R. 289); adopted permanently effective May 19, 1997 (24:10 Md. R. 710) Regulation .07 adopted as an emergency provision effective January 28, 1997 (24:4 Md. R. 289); adopted permanently effective May 19, 1997 (24:10 Md. R. 710) —————— Chapter recodified from COMAR 09.31.23 to COMAR 31.10.12 effective September 7, 1998 (25:18 Md. R. 1439) Regulation .02B amended effective January 1, 2005 (31:23 Md. R. 1655); January 13, 2011 (38:1 Md. R. 12) Regulation .03 amended effective January 13, 2011 (38:1 Md. R. 12) Regulation .03A amended effective January 1, 2005 (31:23 Md. R. 1655) Regulation .04A amended effective January 1, 2005 (31:23 Md. R. 1655) Regulation .05 amended effective January 13, 2011 (38:1 Md. R. 12) Regulation .06 amended effective January 13, 2011 (38:1 Md. R. 12) Regulation .06D amended effective January 1, 2005 (31:23 Md. R. 1655) Regulation .07 amended effective January 13, 2011 (38:1 Md. R. 12) Regulation .08 adopted effective January 1, 2005 (31:23 Md. R. 1655); January 13, 2011 (38:1 Md. R. 12) Authority Insurance Article, §§ 2-109 and 15-120 , Annotated Code of Maryland
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.01 Applicability and Scope. This chapter is applicable to all: A. Carriers as defined in Regulation .02B(1) of this chapter ; B. Consultant/facility providers as defined in Regulation .02B(2) of this chapter ; and C. Primary or requesting providers as defined in Regulation .02B(4) of this chapter .
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.02 Definitions. A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) "Carrier" means: (a) An insurer; (b) A nonprofit health service plan; (c) A health maintenance organization; or (d) A dental plan organization. (2) “Consultant/facility provider” means: (a) A person licensed or certified under Health Occupations Article, Annotated Code of Maryland , who receives a referral from a primary or requesting provider; or (b) Hospitals and related institutions that receive a referral from a primary or requesting provider. (3) "Hospital" has the meaning stated in Health-General Article, §19-301, Annotated Code of Maryland. (4) "Primary or requesting provider" means a person licensed or certified under the Health Occupations Article, Annotated Code of Maryland , who refers patients for consultation to a consultant/facility provider. (5) "Related institution" has the meaning stated in Health-General Article, §19-301, Annotated Code of Maryland. (6) “Uniform consultation referral form” means: (a) For dentists referring patients for dental care procedures or services, the Maryland Uniform Dental Consultation Referral Form or its electronic equivalent shown in Regulation .08 of this chapter ; or (b) For all other health care professionals referring patients for health, medical, or dental care procedures or services, the Maryland Uniform Consultation Referral Form or its electronic equivalent shown in Regulation.06 of this chapter.
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.03 Uniform Consultation Referral Form — Carrier Requirements. A. If a carrier requires a covered person to have a written referral in order to receive services, the carrier shall use the uniform consultation referral form as defined in Regulation .02B(6) of this chapter . B. The carrier may not impose as a condition of coverage a requirement to: (1) Modify the uniform consultation referral form, except as provided in §E of this regulation ; or (2) Submit additional consultation referral forms. C. The carrier may provide a separate set of instructions for properly completing the Uniform Consultation Referral Form. D. For the uniform consultation referral form, the carrier’s specific instructions: (1) If applicable, may be preprinted on the back of the uniform consultation referral form, if the instructions do not result in any modifications in the format of, or information categories directed to be supplied on the front of, the uniform consultation referral form; and (2) Shall be made available to primary or requesting providers on the carrier’s website. E. Notwithstanding the provisions of §B of this regulation , the carrier may provide stamps or preprinted stickers to include additional information to the carrier information block on the uniform consultation referral form. F. The carrier may preprint the designated carrier information in the carrier information field on the Maryland uniform consultation referral form.
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.04 Uniform Consultation Referral Form — Primary or Requesting Provider. A. The primary or requesting provider shall use the uniform consultation referral form as defined in Regulation .02B(6) of this chapter and instructions as provided in Regulation .03C of this chapter . B. The uniform consultation referral form shall be properly completed by the primary or requesting provider.
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.05 Uniform Consultation Referral Form — Consultant/Facility Provider. The consultant/facility provider shall accept a properly completed uniform consultation referral form.
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.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:
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C. The electronic equivalent of the uniform consultation referral form is as follows:
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Electronic Equivalent of the Uniform Consultation Referral Form
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Field Length Start Stop
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1 - Patient last name 18 1 18
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2 - Patient first name 12 19 30
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3 - Patient MI 1 31 31
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4 - Patient DOB 8 32 39
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5 - Patient phone number 10 40 49
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6 - Patient member number 16 50 65
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7 - Patient site number 10 66 75
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8 - Carrier name 24 76 99
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9 - Carrier address 1 24 100 123
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10 -Carrier address 2 24 124 147
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11 - Carrier city 24 148 171
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12 - Carrier state 2 172 173
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13 - Carrier zip code 9 174 182
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14 - Carrier phone number 10 183 192
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15 - Carrier fax number 10 193 202
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16 - Primary/requesting provider last name 18 203 220
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17 - Primary/requesting provider first name 12 221 232
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18 - Primary/requesting provider MI 1 233 233
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19 - Primary/requesting provider specialty 25 234 258
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20 - Primary/requesting provider institution/group name 80 259 338
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21 - Primary/requesting provider NPI # 10 339 348
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22 - Primary/requesting provider address 1 24 349 372
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23 - Primary/requesting provider address 2 24 373 396
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24 - Primary/requesting provider city 24 397 420
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25 - Primary/requesting provider state 2 421 422
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26 - Primary/requesting provider zip 9 423 431
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27 - Primary/requesting provider phone 10 432 441
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28 - Primary/requesting provider fax 10 442 451
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29 - Consultant/facility provider last name 18 452 469
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30 - Consultant/facility provider first name 12 470 481
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31 - Consultant/facility provider MI 1 482 482
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32 - Consultant/facility provider specialty 25 483 507
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33 - Consultant/facility provider institution/group name 80 508 587
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34 - Consultant/facility provider NPI # 10 588 597
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35 - Consultant/facility provider address 1 24 598 621
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36 - Consultant/facility provider address 2 24 622 645
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37 - Consultant/facility provider city 24 646 669
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38 - Consultant/facility provider state 2 670 671
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39 - Consultant/facility provider zip 9 672 680
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40 - Consultant/facility provider phone 10 681 690
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41 - Consultant/facility provider fax 10 691 700
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42 - Reasons for referral 80 701 780
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43 - Brief history, dx, results or attachment 120 781 900
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44 - Service desired - code 2 901 902
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45 - Place of service - code 2 903 904
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46 - Number of visits 2 905 906
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47 - Authorization number 10 907 916
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48 - Referral validity date 8 917 924
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49 - Signature/electronic person completing the form 30 925 954
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50 - Authorized signature/electronic 30 955 984
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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.
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.07 Electronic Transfer of the Uniform Consultation Referral Form. A. A transmission by facsimile is not considered an electronic transfer for the purposes of this chapter. B. A carrier shall accept the electronic transfer of the uniform consultation referral form.
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.08 Uniform Consultation Referral Form — Required Forms. A. The Maryland Uniform Dental Consultation Referral Form shall read as follows: (SEE NEXT PAGE)
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B. The electronic equivalent of the uniform consultation referral form is as follows:
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Uniform Dental Consultation Referral
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Field Length Start Stop
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1 - Patient last name 18 1 18
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2 - Patient first name 12 19 30
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3 - Patient MI 1 31 31
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4 - Patient DOB 8 32 39
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5 - Patient phone number 10 40 49
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6 - Patient member number 16 50 65
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7 - Patient site number 10 66 75
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8 - Carrier name 24 76 99
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9 - Carrier address 1 24 100 123
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10 -Carrier address 2 24 124 147
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11 - Carrier city 24 148 171
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12 - Carrier state 2 172 173
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13 - Carrier zip code 9 174 182
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14 - Carrier phone number 10 183 192
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15 - Carrier fax number 10 193 202
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16 - Primary/requesting dentist last name 18 203 220
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17 - Primary/requesting dentist first name 12 221 232
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18 - Primary/requesting dentist MI 1 233 233
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19 - Primary/requesting dentist specialty 25 234 258
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20 - Primary/requesting dentist institution/group name 80 259 338
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21 - Primary/requesting dentist NPI # 10 339 348
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22 - Primary/requesting dentist address 1 24 349 372
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23 - Primary/requesting dentist address 2 24 373 396
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24 - Primary/requesting dentist city 24 397 420
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25 - Primary/requesting dentist state 2 421 422
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26 - Primary/requesting dentist zip 9 423 431
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27 - Primary/requesting dentist phone 10 432 441
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28 - Primary/requesting dentist fax 10 442 451
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29 - Specialist dentist last name 18 452 469
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30 - Specialist dentist first name 12 470 481
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31 - Specialist dentist MI 1 482 482
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32 - Specialist dentist specialty 25 483 507
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33 - Specialist dentist institution/group name 80 508 587
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34 - Specialist dentist NPI # 10 588 597
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35 - Specialist dentist address 1 24 598 621
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36 - Specialist dentist address 2 24 622 645
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37 - Specialist dentist city 24 646 669
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38 - Specialist dentist state 2 670 671
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39 - Specialist dentist zip 9 672 680
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40 - Specialist dentist phone 10 681 690
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41 - Specialist dentist fax 10 691 700
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42 - Reasons for referral 80 701 780
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43 - Brief history, dx, results or attachment 120 781 900
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44 - Service desired - code 2 901 902
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45 - Place of service - code 2 903 904
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46 - Teeth diagram - attachment 2 905 906
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47 - Authorization number 10 907 916
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48 - Referral validity date 8 917 924
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49 - Signature/electronic person completing the form 30 925 954
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50 - Authorized signature/electronic 30 955 984
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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.
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Previous Chapter 11 Uniform Claims Forms
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Next Chapter 13 Return of Premium, Cash Surrender, or Other Nonforfeiture Benefits in Health Insurance Policies
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