Provider Claim Appeals Submission Form

General Information

Guidelines

Please use this form as part of the Maryland Physicians Care (MPC) Appeal process to address the decision made during the request for review process. Do not use this form for first-time claims or corrected claims.

ATTENTION: Do not use this form for provider inquiries, resubmissions, or corrected claims. This form is only to be used for appealing denied or partially denied claims.

All Appeal requests must be received within 90 business days from the date of the Medicaid Remittance. All fields are required. Please note the claim number is mandatory. Failure to complete the form will preclude the appeal from being submitted successfully.

Appeal File Upload

PDF files only.

Attachment Requirements

Please use this field to include any documents that you want reviewed within your appeal. An attachment for claim denials must include a cover letter explaining the reason why you are disagreeing with the claim denial or reduction of service for your appeal as well as any documentation that is relevant to support your appeal.

NOTE: There is a 256 MB maximum. If your attachment exceeds this, or you cannot combine your documents into one attachment, please submit your claim appeal via fax to (833) 656–0648 or mail the Appeals form, with attachment(s) to:

Maryland Physicians Care
P.O. Box 1104
Portland, ME 04104




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