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Mpc can also mail or fax the appeal form to you and assist in completing the form Authorized representative for member appeal form submit this form to If you have questions for maryland physicians care or need additional information, click this link to contact mpc
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Access and download pdf versions of key forms accepted by maryland physicians care for medical requests, claims, referrals and more. If your health care provider has determined that certain medical treatment is needed, but your hmo or health insurer does not agree, this law allows you to appeal. Please be sure to fax/mail the appeal to the appropriate number/address noted below, thoroughly complete the application form, and attach the required medical records and consent forms as applicable
Mail or fax form and documentation
Please note that member consent is required. Please include relevant claim information and any supporting medical or clinical documentation with this form and submit electronically, via fax, or mail to the following address: Attachments must be submitted as pdfs Box 1104 portland, me 04104
Complete the appeal form, which can be found online at Marylandphysicianscare.com/ providers/forms/html mail or fax form and documentation to Enroll electronically with payspan by visiting my mpc source, our secure web portal Maryland law gives maryland consumers the right to appeal a decision that denies you coverage for medically necessary treatment
