Instructions For Completion Of Form 4510 - Maryland Department Of Health printable pdf download

Instructions For Completion Of Form 4510 - Maryland Department Of Health

Maryland Department of Health

Office for Genetics and Children with Special Health Care Needs

Children’s Medical Services (CMS)

Request for Pre-Authorization of Services

Instructions for Completion of Form 4510

NOTE: All providers must initiate and complete Form 4510. CMS regulations, Children’s Medical Services

Program (COMAR 10.11.03), mandate that the Providers of service request authorization on forms designated by

CMS. The Provider must initiate this process via Form 4510 when service to a CMS eligible patient is anticipated.

Mail or FAX the completed form to CMS as directed on Form 4510.

Provider#

Lines 1-5

Enter the Provider’s Medical Assistance Provider

Begin, End – Enter a specific date under “Begin”

and “End” if possible or indicate range of dates

Number which will be used for billing for the

type of service to be provided.

within which you anticipate providing the service.

CPT Code – Enter the five (5) digit Medicaid

Provider/Facility

Insert the name of the Provider/Facility and Clinic

billing CPT or HCPCS code for all services

which the service will be billed.

excluding hospital facility services.

Procedure – Enter a description of the procedure,

Phone and Fax

Enter the appropriate numbers to the areas where

item or service.

the service will be provided.

Number of Services – For non-hospital services,

Child’s SSN/CMS#

enter the number of services.

Insert the patient’s nine (9) digit Social Security

Estimated Charge – Enter an estimate of the

Number or CMS number.

charge for the service.

County or Baltimore City

Enter the patient’s county of residence or “CITY”

Signature, Title and Telephone

for Baltimore City residents.

Enter the person who will respond to questions

from CMS staff about the request. Date the

Health Insurance

request.

If applicable, enter the patient’s private insurance

company’s Name and policy number.

Send Authorization to:

Enter the person and/or office address to which the

Diagnosis

CMS written authorization should be sent.

Enter the patient’s diagnosis or description of

problem which relates to this request.

Telephone/ FAX

Enter the numbers of the office which should

Service(s) Requested

receive the written CMS authorization.

Check the appropriate block. Add a comment

to specify “Other”.

Instructions 4510 REV 5/15

Instructions For Completion Of Form 4510 - Maryland Department Of Health

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