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COMAR 10.09.24.11

1105 State of Maryland Medical Assistance Manual Revised July 2012 Attachment A-DHR/IMA 81 Form

MARYLAND DEPARTMENT OF HUMAN RESOURCES INCOME MAINTENANCE ADMINSTRATION

Department of Social Services

Date:

Recipient Name:

_______

Recipient Address:

M.A. Number:

TO: Chief, Division of Invoice Processing Medical Assistance Operations Administration 201 W. Preston Street, Room SS-18 Baltimore, Maryland 21201

Dear Sir: Due to an administrative error, Medical Assistance was not previously authorized for the above named recipient. However, we have checked our records and found that he/she was eligible and has now been properly certified for the period from

To

Month Day

Year

Month Day

Year

Please accept medical providers‟ claims for this time period at this time and override the statue of limitations if necessary.

We regret any inconvenience that has been caused. If you have any further questions, please do not hesitate to contact me at

.

(Telephone Number)

Sincerely,

cc:

Signature of Approving Authority

Provider Name

Provider Name

Provider Name

NOTE TO PROVIDER: Please submit a copy of this letter and the appropriate invoice for all claims for this period within 6 months of the date of this letter.