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

Attachment Requirements

Please use this section to upload your cover letter separately from any supporting documentation that you want reviewed within your appeal.

• Prepare supporting files by placing them in a single folder so they can be uploaded in one step. (Uploading multiple files separately will overwrite files previously uploaded.)
• Any number of PDFs can be included in the Supporting Documentation upload.
• The cover letter must explain the reason why you are disagreeing with the claim denial or reduction of service for your appeal.
• Include any documentation that is relevant to support your appeal in the Supporting Documentation upload.
• This is a secure website. Please ensure that your attachments are not password protected.
• There is a 256 MB combined maximum on attachments and 100 MB maximum on individual PDFs uploaded.
• Attachments must be submitted as PDFs.

If your attachments do not meet these requirements, or you cannot provide your cover letter separately, 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