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Get Tufts Inpatient Notification Form
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How to fill out the Tufts Inpatient Notification Form online
Filling out the Tufts Inpatient Notification Form online is a crucial process for ensuring proper documentation and communication regarding admissions for Tufts Health Plan members. This guide provides clear and comprehensive steps to assist you in accurately completing the form.
Follow the steps to smoothly complete the form.
- Click ‘Get Form’ button to access the Tufts Inpatient Notification Form and open it in your preferred editor.
- Enter the requestor's name, phone number, and fax number at the top of the form. This information identifies the person submitting the notification.
- Fill in the member's name, member ID number, and date of birth to ensure accurate identification of the patient.
- Provide the admitting physician's name and phone number, as well as the admitting facility's name and contact number for follow-up purposes.
- Specify the inpatient admission date, ensuring it aligns with the actual date of treatment.
- If applicable, include the prior observation date to give context to the patient's history.
- Indicate whether the member has other health insurance coverage by selecting 'Yes' or 'No'. If 'Yes', provide the name of the other insurance policy and the policy number.
- Include the ICD-10 diagnosis codes, ensuring that at least one is listed for service dates on or after October 1, 2015.
- Input the required ICD-10 or CPT procedure codes for the procedures performed during the admission.
- Fill in the primary care provider’s name and indicate whether there is a PCP referral for this admission by selecting 'Yes' or 'No'. If there is a referral, include the referral number.
- If applicable, enter the prior authorization number for the admission to facilitate processing.
- Select the appropriate request type from the options provided, indicating the status of the admission.
- Document the name of Tufts Health Plan authorizing care manager, if available.
- Add any relevant comments that may assist in the review process.
- After completing all fields, ensure to save changes to the form. You may then download, print, or share the notification form as needed.
Start completing the Tufts Inpatient Notification Form online now to ensure all necessary information is submitted accurately.
As a reminder, while prior authorization is not required for out-of-network services, providers and members are encouraged to request a pre-visit coverage decision from Tufts Health Plan before rendering/seeking out-of- network services.