Request Auth Corrections

To request corrections to authorizations that have been approved for dates of service on or after 7/1/2020, please complete the following information:

Please note that initial and retro-authorization requests will not be accepted through this box.

Requests to add codes will not be accepted via this form. If you need to add a code, prior to May 1, 2021 you may submit an authorization through the Incedo portal, backdated to the start of the original authorization, for the desired code. If the desired code does not display on your authorization request screen, this may be due to an issue with your profile set-up, please contact provider relations.

Submitter Name

Name of the person submitting the claim

Submitter Email Address

Email address of the submitter

Submitter Phone Number

Phone number of the person submitting the form

NPI #

Provider Name

This name must be exactly as it appears on the service request.

Provider Site

Street Address 1

Street Address 2

City

State

Zip Code

Service Request ID

Only one service request id per request

Member Full Name

Member Date of Birth

Maryland Medicaid ID

CPT / Rev Code

All

Specific CPT / Rev Codes

Specific value of CPT, Rev, or Service:

What is the issue that needs to be fixed:

Wrong Start Date

Wrong provider address chosen

Wrong units entered (and no clinical review for additional units required)

Other

Explanation