Get Out Of State Acute Inpatient Fax Assessment Form - Bcbsm.com

Filling out the Out Of State Acute Inpatient Fax Assessment Form is essential for initiating the precertification process for acute inpatient admissions. This guide provides a clear, step-by-step approach to help you complete the form correctly and efficiently online.

Follow the steps to successfully complete the assessment form.

1. Press the ‘Get Form’ button to access the form and open it in your chosen editing platform.
2. Begin by entering the patient's personal information, including their name, date of birth, and policy number. Ensure all details are accurate and legible.
3. In the contact information section, provide the facility name, address, city, and state. Include the contact person's name and their phone number.
4. Complete the admitting physician's information, including their name, NPI number, address, and contact number.
5. In the medical admissions section, specify the admitting diagnosis along with the corresponding ICD9 codes.
6. If surgical admissions apply, provide the surgical procedure and CPT codes along with the surgery date and surgical diagnosis.
7. Estimate the length of stay and indicate the admission date, ensuring that all requested fields are filled out.
8. In the recertification section, detail the current estimated length of stay and the last covered date.
9. Finally, review the completed form for accuracy, save your changes, and then download or print it for faxing to the designated number.
10. Consider sharing the form electronically if required and ensure that all supplementary documents, such as hospital admission notes, are included.

Complete your documents online to streamline the process efficiently.