MDOC Denial Medical Record Submission

Did you receive a denial code (252 and/or M127) for missing medical documentation (MDOC)? Please only use this form in response to 252 and/or M127 denial codes.
Note: This form and fax line is not to be used for any other documentation submission.

* Required Fields

Claim Information

Todays Date: 4/26/2024

Claim Number: *

Date of Service: *

Service Type:*
Medical Pharmacy

If documentation is required for both Medical and Pharmacy lines on claim then please submit a form for Medical and Pharmacy separately with the same claim number.

Provider Information

Billing Provider NPI: *

Provider Name: *

Provider Office Contact: *

Office Contact Email: *

Office Contact Phone Number: *

Office Contact Fax Number:

Member Information

Member Name: *

Member Date of Birth: *

Member ID Number: *

Medical Record Number:

Notes

Enter Claim Notes:

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