Follow the steps to complete the authorization request form effectively.

1. Click ‘Get Form’ button to access the TN BCBS Skilled Nursing Facility/Inpatient Rehabilitation Authorization Request form and open it for editing.
2. Begin filling out the 'Initial Request' section, selecting between initial request or concurrent review depending on your needs.
3. In the 'Member Information' section, fill in the member's name, date of birth, identification number, reference number, and current telephone number.
4. Proceed to the 'SNF/Inpatient Rehabilitation Facility Information' section. Enter the expected admission date, facility name, contact name, and confirm if the facility is 'in network' with BlueCross BlueShield of Tennessee. Also, provide the facility's address, phone number, fax number, provider number, and NPI number.
5. In the 'Ordering Physician Information' section, enter the prescribing physician's name and confirm if they are 'in network'. Fill in their address, phone number, fax number, provider number, and NPI number.
6. Navigate to the 'Admitting Physician Information' section, including the facility physician's name and network status. Provide their address, phone number, fax number, provider number, and NPI number.
7. Complete the 'Clinical Information' section, detailing the diagnosis, co-morbidities, height, weight, type of surgery, and date of surgery. Specify pain control measures at discharge.
8. Document patient orientation and cognition in the 'Patient Level of Orientation' section, including the Rancho level and cognitive function.
9. In the 'Types of Discipline' section, indicate the types of therapy required and the expected number of therapy hours per day.
10. Provide information on the patient's functional status prior to admission and home environment details, like single or multi-level home and caregiver availability.
11. Fill out the 'Current Functional Status' section with FIMS scores across various categories like eating, dressing, and ambulation.
12. Detail wound care descriptions, progress toward goals, and any additional skilled needs in the respective sections.
13. Finally, specify estimated length of stay, discuss discharge goals, and indicate the post-discharge destination.
14. Once all sections are filled, users can save changes, download, print, or share the completed authorization request form.

Start filling out your TN BCBS Skilled Nursing Facility/Inpatient Rehabilitation Authorization Request online today!