Get Bluecare Tn Form

Filling out the Bluecare Tn Form online can be a straightforward process if you follow the necessary steps. This guide provides clear instructions to help you complete the form accurately and efficiently to ensure your requests are properly submitted.

Follow the steps to complete the Bluecare Tn Form online.

1. Click 'Get Form' button to obtain the form and open it for your input.
2. Begin filling out the member information section. Provide the member name, member ID number, date of birth, and the diagnosis with all relevant ICD-9/10 codes.
3. Next, complete the physician and facility information. Include the ordering physician's name, provider number, national provider identifier, Tennessee Medicaid number, as well as the contact details such as phone and fax numbers.
4. Fill in the facility name and its corresponding details, including the provider number, national provider identifier, Tennessee Medicaid number, and contact information.
5. Specify the start and end date for the services being requested, along with the date of evaluation.
6. Clearly state the services being requested, including the frequency and number of requests.
7. Indicate any conservative treatments that have been used or failed, along with the date of previous treatments and the date of the last medical assessment or follow up.
8. List any related problems, providing as much detail as possible.
9. Include the codes or services requested, ensuring you provide the corresponding codes along with the number of units or days required for each.
10. If necessary, attach any clinical information such as records, lab results, or imaging results. Ensure to follow any specific guidelines per BlueCare Tennessee Medical Policy as required.
11. After completing the form, review your entries for accuracy. Once satisfied, you can save changes, download, print, or share the form as necessary.

Start completing your Bluecare Tn Form online today!