MCM Maxcare Providers: Submit A Pre-Certification


	MCM Maxcare Provider Benefits Request Demographic Info Review Group Benefits/Exclusions Submit A Pre-Certification Join The MCM Network


	Submit A Pre-Certification

Use this form to begin the pre-certification process for an MCM member.
Remember: Completion of this form does not guarantee the member's claim will be approved.

NOTE: All fields (except Comments) are required.

All Clinicals/Support Documents for Pre-Approval Must be Faxed to 850-385-4104

MEMBER INFORMATION

Member ID Number:

Member Name:

Patient Name:

DOCTOR INFORMATION

Hospital/Facility Name:

Hospital/Facility Phone:

Contact Name:

Best Time To Call:

Doctor's Name:

Name of Practice:

E-Mail:

Phone Number:

Address:

City:

State:

Zip Code:

PROCEDURE INFORMATION

CPT Code 1:

CPT Code 2: (optional)

CPT Code 3: (optional)

DX Code 1:

DX Code 2: (optional)

DX Code 3: (optional)

Procedure Status: Out-PatientIn-Patient

Date of Procedure:

Procedure Description:

Diagnosis Description:

Comments (Optional):

MCM Maxcare is a preferred provider network of Medical Claims Management
Medical Claims Management, Inc. � P. O. Box 1176 � Tallahassee, Florida 32302
850-553-4644 � Fax: 850-402-8961
Please report problems to WebMaster@MCMMaxcare.com.
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