How to Complete and Submit the Maryland Uniform Consultation Referral Form

The Maryland Uniform Consultation Referral Form is the standardized document a primary care or requesting provider must use to refer a patient to a specialist, hospital, or other facility when the patient’s carrier requires a written referral. Maryland’s insurance regulations under COMAR 31.10.12 require every carrier that accepts written referrals to use this single form, and carriers cannot force providers to submit proprietary paperwork in its place.¹ The form captures patient demographics, insurance data, referring and consulting provider information, and the clinical reason for the referral across 50 defined data fields. The walkthrough below covers who the rule binds, how to complete each section, how to submit it, and how long a response should take.

Who the Form Applies To

COMAR 31.10.12 reaches three groups: carriers, primary or requesting providers, and the consultant or facility providers who receive referrals. “Carrier” includes insurers, nonprofit health service plans, health maintenance organizations, and dental plan organizations operating in Maryland. If a carrier requires a covered person to have a written referral before receiving services, the carrier must use the uniform form, with no add-on paperwork permitted.¹

One boundary matters before you start. Self-insured employer health plans governed by the federal Employee Retirement Income Security Act may not be bound by this state regulation; ERISA preemption can block states from imposing standardized administrative processes on self-funded plans. If a patient’s coverage comes through a self-insured employer plan rather than a state-regulated carrier, that carrier may require its own referral paperwork. Fully insured plans purchased through a Maryland-licensed carrier fall squarely under COMAR 31.10.12.

There is also a separate Maryland Uniform Dental Consultation Referral Form defined in COMAR 31.10.12.08 that dentists use for dental procedures. The rest of this guide covers the general medical form in COMAR 31.10.12.06.¹

Completing the 50 Fields

The form has 50 numbered data fields organized into five blocks. The regulation requires the form to be “properly completed” by the requesting provider, and the consultant or facility on the receiving end must accept any form that is properly completed.¹ Gaps in required information are the fastest route to a delayed authorization.

Patient Information (Fields 1 Through 7)

Begin with the patient’s last name, first name, and middle initial in fields 1 through 3. Field 4 is date of birth in an eight-character format. Field 5 is the phone number. Field 6 is the patient’s member number, which is the subscriber ID printed on the insurance card, not a Social Security number. Field 7 is the patient site number, which some carriers use to identify the specific clinic location tied to the patient’s primary care assignment.²

Carrier Information (Fields 8 Through 15)

Fields 8 through 15 identify the insurance carrier: name, mailing address (two address lines, city, state, and zip code), phone number, and fax number. Pull this directly from the patient’s insurance card or the carrier’s provider directory. If the office submits by fax, double-check the carrier’s fax number, and note that fax transmission is not treated as an “electronic transfer” under COMAR 31.10.12.07.¹

Referring Provider Information (Fields 16 Through 28)

The referring provider block mirrors the patient section. Enter the provider’s last name, first name, middle initial, and specialty in fields 16 through 19, then the institution or group name in field 20 (up to 80 characters). Field 21 is the referring provider’s 10-digit National Provider Identifier. Fields 22 through 28 capture the full mailing address, phone, and fax.²

Consultant or Facility Provider Information (Fields 29 Through 41)

Fields 29 through 41 use the same layout for the specialist or facility receiving the referral: name, specialty, institution or group, NPI in field 34, address, phone, and fax. If the referral goes to a facility rather than an individual physician, such as a hospital imaging center, list the facility’s information here. The consultant’s NPI needs to be accurate because the carrier uses it to confirm the specialist is in-network and to route the authorization.²

Clinical and Authorization Details (Fields 42 Through 50)

Referrals stall most often in this block. Field 42 gives 80 characters for the reason for referral. Be specific and clinical. “Evaluate persistent left knee pain unresponsive to conservative treatment” works; “orthopedic consult” does not. Field 43 provides 120 characters for a brief history, diagnosis, and results, or an indication that an attachment is included. The form itself does not list ICD-10 codes as a required element, but including the relevant diagnosis code in the history field helps the carrier’s utilization management team process the request faster and reduces follow-up requests for additional clinical notes.²

Fields 44 and 45 use two-character codes for the service desired and the place of service. Field 46 is the number of visits requested, as a two-character entry (so up to 99). Field 47 holds the carrier’s authorization number once issued. Field 48 is the referral validity date, meaning the date through which the referral remains active. Fields 49 and 50 are signature lines: one for the person who completed the form and one for the authorized signer, either handwritten or electronic.²

Where to Find the Form

The form’s structure and field specifications are published in COMAR 31.10.12.06, and the Maryland Insurance Administration posts provider resources at insurance.maryland.gov.³ Many carriers also distribute pre-printed copies to participating provider offices, and each carrier must make its referral-completion instructions available on its own website.¹

Carriers are permitted to print their own specific instructions on the back of the form, as long as those instructions don’t alter the format or information categories on the front. If a carrier’s materials appear to add fields or require a supplemental form, that likely runs afoul of COMAR 31.10.12.03, which bars carriers from modifying the form or requiring additional referral forms as a condition of coverage.

Submitting the Form

Maryland carriers must accept electronic transfer of the uniform consultation referral form. The regulation draws a clear line between electronic transfer and fax: a faxed copy does not count as an electronic submission under COMAR 31.10.12.07.¹ In practice, most Maryland carriers offer a secure provider portal for uploading referral requests, and many electronic health record systems can generate and transmit the form’s data fields electronically using the field layout specified in COMAR 31.10.12.06.

For offices that still rely on fax, carriers do accept faxed copies; the regulation simply doesn’t classify fax as the “electronic transfer” that carriers are required to support. Either way, keep a confirmed copy. If a dispute later arises about whether the referral was submitted or when it was received, the timestamp on an electronic submission or the fax confirmation page becomes critical evidence.

One disclaimer appears on both the paper and electronic versions of the form: referral certification is not a guarantee of payment. The patient’s eligibility must still be active on the date of service, and the visit must fall within the plan’s contractual provisions.²

How Long the Carrier Has to Respond

Some Maryland carriers process routine referral determinations within two business days of receiving all necessary information.⁴ For emergencies, Maryland insurers must offer an expedited procedure that produces a decision within 24 hours.⁵ Emergency inpatient admissions at some carriers are reviewed within two hours of receipt.

Beginning in 2026, a federal ceiling also applies. The CMS Interoperability and Prior Authorization Final Rule requires impacted payers to issue prior authorization decisions within seven calendar days for standard requests and 72 hours for urgent or expedited requests involving medical items and services.⁶ Once the carrier reaches a decision, it documents the determination in its utilization management system and issues authorization letters to both the referring provider and the patient.⁷

If the Referral Is Denied

A denial must come with a written explanation that includes the reason for the decision and details about the carrier’s internal grievance process, along with a direct phone number and email address for the appeals team.⁵ Read the denial letter closely before deciding on next steps.

The first move is an internal appeal through the carrier’s grievance process. Federal rules give the carrier 30 days to decide appeals for services not yet received and 60 days for services already rendered. For urgent situations, the carrier must issue a decision as quickly as the medical condition requires, and no later than four business days after receiving the appeal.⁸

After exhausting the carrier’s internal grievance process, a patient or authorized representative can file a complaint with the Maryland Insurance Administration within four months of the carrier’s final grievance decision. Complaints can be submitted through the MIA’s online portal, by mail, by fax, or by email to agcomplaints.mia@maryland.gov. The MIA is located at 200 St. Paul Place, Suite 2700, Baltimore, MD 21202. Most complaints are resolved within 90 days, though some take longer.⁹

There is an exception to the exhaust-first rule. If a delay could result in loss of life, serious bodily harm, serious organ dysfunction, or danger from ongoing mental illness or substance use, the MIA treats that as a “compelling reason” to skip the internal process. Emergency cases are expedited, with a decision required within 24 hours.⁹ Federal law also provides for an independent external review of any denial that involves medical judgment or a determination that a treatment is experimental, and a written request must be filed within four months after the final denial notice.¹⁰

1
Library of Maryland Regulations. COMAR 31.10.12 – Uniform Consultation Referral
2
Cornell Law Institute. Maryland Code of Regulations 31.10.12.06 – Uniform Consultation Referral Form
3
Maryland Insurance Administration. Health Care Providers
4
UnitedHealthcare. Information About Referrals to Providers for Members of Maryland Health Care Plans
5
Maryland Insurance Administration. Appeals and Grievance
6
Centers for Medicare & Medicaid Services. CMS Finalizes Rule to Expand Access to Health Information and Improve Prior Authorization Process
7
Maryland Insurance Administration. Commercial Carrier Process to Request a Referral to a Specialist or Non-Physician Specialist
8
HealthCare.gov. Internal Appeals
9
Maryland Insurance Administration. File A Complaint
10
HealthCare.gov. External Review